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  • 1
    Publication Date: 2010-02-11
    Description: Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2nd Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3rd Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.
    Description: Ein gezieltes Monitoring von Analgesie, Sedierung und Delir sowie das adäquate therapeutische Management bei kritisch kranken Patienten auf Intensivstationen ist eine Basismaßnahme jeder intensivmedizinischen Behandlung. Aus den unumstrittenen Vorteilen einer leitlinienorientierten Therapie ergab sich die Notwendigkeit der Entwicklung von eigenen Leitlinien zur Analgesie und Sedierung in der Intensivmedizin für Deutschland, die als S2 Leitlinie 2005 veröffentlicht wurde. Durch die Verbreitung dieser Leitlinie wurde 2006 eine Verbesserung des Monitorings von 8 auf 51% und eine Steigerung von protokollbasiertem Vorgehen von 21 auf 46% festgestellt werden.Von 2006-2009 wurde die bestehende S2 Leitlinie von der DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) und der DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) unter Bündelung aller verfügbaren Kräfte zur Sicherung und Verbesserung der Qualität der Analgesie und Sedierung sowie zur Delirbehandlung auf der Intensivstation auf eine S3-LL erweitert. In Zusammenarbeit mit weiteren 10 Fachgesellschaften wurde die Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Unter Berücksichtigung von 671 Literaturstellen wurden Volltext, Schemata und Empfehlungen erstellt. In den Empfehlungen wurden die Grade "A" (sehr starke Empfehlung), "B" (starke Empfehlung) und "0" (offene Empfehlung) gewählt.Als Ergebnis dieses Prozesses liegt nun eine interdisziplinär erarbeitete evidenz- und konsensbasierte Stufe 3 Leitlinie vor, die alle kritisch kranken Patientengruppen berücksichtigt.Der Nutzen von Protokollen in der Analgosedierung und bei der Delirbehandlung wurde vielfach gezeigt. Diese Leitlinie bietet eine Handlungsempfehlung für das intensivmedizinische Team. Für die Umsetzung ist die Implementierung von Scores und Protokollen in den klinischen Alltag in der Intensivmedizin erforderlich.
    Keywords: guideline ; evidence ; analgesia ; sedation ; delirium ; monitoring ; treatment ; intensive care ; Leitlinie ; Analgesie ; Sedierung ; Delir ; Monitoring ; Therapie ; Intensivmedizin ; ddc: 610
    Type: article
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  • 2
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    German Medical Science GMS Publishing House; Düsseldorf
    In:  21. Jahrestagung der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI); 20130425-20130427; Würzburg; DOC13dgpi33 /20130328/
    Publication Date: 2013-03-29
    Keywords: ddc: 610
    Language: German
    Type: conferenceObject
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  • 3
    Publication Date: 2015-11-16
    Description: In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
    Description: Die vorherige Version der S3-Leitlinie "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" wurde 2010 unter der Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) publiziert. Neue Evidenz aus Studien ebenso wie neue Leitlinien, u.a. die 2013 erschienene Leitlinie der U.S.-amerikanischen Society of Critical Care Medicine (SCCM), des American College of Critical Care Medicine (ACCM) und der American Society of Health-System Pharmacists (ASHP), gaben nicht nur Anlass zu einem Update der deutschen Empfehlungen von 2010. Für die Fortschreibung der S3-Leitlinie wurden eine Neuformulierung von klinisch relevanten Schlüsselfragen und die signifikante Erweiterung der Leitlinie um neue Facetten der Behandlung, wie zum Beispiel das Schlafmanagement, notwendig. Dazu wurde die systematisch gesuchte Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Der enorme Evidenzkörper bildete die Grundlage für die Empfehlungen, die von Mandatsträgern aus 17 Fachgesellschaften konsentiert wurden. In den Empfehlungen wurden die Grade "A" (starke Empfehlung), "B" (Empfehlung) und "0" (offene Empfehlung) gewählt. Als Ergebnis dieses Prozesses liegt nun die weltweit umfassendste, interdisziplinär erarbeitete evidenz- und konsensbasierte Stufe 3 Leitlinie vor. Die Leitlinie richtet sich an alle auf der Intensivstation tätigen Berufsgruppen, die Empfehlungen berücksichtigen alle intensivmedizinisch-behandelten Patientengruppen. Sie stellt einen Leitfaden zur symptomorientierten Prävention, Diagnostik und Therapie von Delir, Angst, Stress und der protokollbasierten Analgesie, Sedierung und dem Schlafmanagement in der Intensivmedizin für Erwachsene und Kinder dar.
    Keywords: guideline ; evidence ; analgesia ; sedation ; delirium ; anxiety ; stress ; sleep ; monitoring ; treatment ; intensive care ; critical care ; Germany ; Leitlinie ; Analgesie ; Sedierung ; Delir ; Angst ; Stress ; Schlaf ; Monitoring ; Therapie ; Intensivmedizin ; ddc: 610
    Language: English
    Type: article
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  • 4
    ISSN: 1432-1076
    Keywords: Mucopolysaccharidoses ; Mitral regurgitation ; Aortic regurgitation ; Doppler echocardiography
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract In echocardiographic and necropsy studies nodular thickening of the mitral valve and, less frequently, of the aortic valve has been found in 60%–90% of patients with mucopolysaccharidoses (MPS). Little is known about the haemodynamic consequences of these morphological changes. In this study 84 unselected patients with different enzymatically proven MPS and 84 age and sex matched, healthy persons were studied prospectively by colour Doppler flow mapping. The patients' age ranged from 1 to 47 years (median 8.1 years). Mitral and aortic regurgitation were defined as a holosystolic or holodiastolic jet originating from the valve into the left atrium or the left ventricular outflow tract, respectively, with peak velocities exceeding 2.5 m/s. Of the 84 patients with satisfactory studies, mitral regurgitation was detected in 64.3% and aortic regurgitation in 40.5%, respectively. Regurgitation was severe in 4.8% of mitral valves and 8.3% of aortic valves. The frequency of aortic and/or mitral regurgitation was 75% in all patients, 89% in MPS I, 94% in MPS II, 66% in MPS III, 33% in MPS IV, and 100% in MPS VI. Combined mitral and aortic regurgitation was present in 29% of our patients. None of the control persons showed mitral or aortic regurgitation.
    Type of Medium: Electronic Resource
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  • 5
    ISSN: 1432-1238
    Keywords: Fick principle ; Thermodilution ; Cardiac output ; Infants ; Cardiac surgery
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To compare a system that continuously monitors cardiac output by the Fick principle with measurements by the thermodilution technique in pediatric patients. Design Prospective direct comparison of the above two techniques. Setting Pediatric intensive care unit of a university hospital. Patients 25 infants and children, aged 1 week to 17 years (median 10 months), who had undergone open heart surgery were studied. Only patients without an endotracheal tube leak and without a residual shunt were included. Methods The system based on the Fick principle uses measurements of oxygen consumption taken by a metabolic monitor and of arterial and mixed venous oxygen saturation taken by pulse- and fiberoptic oximetry to calculate cardiac output every 20 s. Interventions In every patient one pair of measurements was taken. Continuous Fick and thermodilution cardiac output measurements were performed simultaneously, with the examiners remaining ignorant of the results of the other method. Results Cardiac output measurements ranged from 0.21 to 4.55 l/min. A good correlation coefficient was found:r 2=0.98;P〈0.001; SEE=0.14 l/min. The bias is absolute values and in percent of average cardiac output was −0.05 l/min or −4.4% with a precision of 0.32 l/ min or 21.3% at 2 SD, respectively. The difference was most marked in a neonate with low cardiac output. Conclusion Continuous measurement of cardiac output by the Fick principle offers a convenient method for the hemodynamic monitoring of unstable infants and children.
    Type of Medium: Electronic Resource
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  • 6
    ISSN: 1432-1076
    Keywords: Newborns ; Dobutamine ; Systolic time intervals ; Echocardiography
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract To evaluate the effects of dobutamine on myocardial function in newborns, left ventricular systolic time intervals (STI) — normalized pre-ejection period (PEPI), normalized left ventricular ejection time (LVETI) and pre-ejection period to left ventricular ejection time ratio (PEP/LVET) — were assessed by echocardiography in 18 newborns treated with dobutamine for clinically diagnosed heart failure. Examinations were performed prior to and 30 min after starting dobutamine infusion (7.5 or 10 μg/kg per min). Patients were assigned to two groups according to their PEP/LVET prior to dobutamine administration: group I (n=9) with pre-treatment PEP/LVET ≤ 0.35 and group II (n=9) with pre-treatment PEP/LVET 〉 0.35. While there was no change of STI in group I, dobutamine infusion resulted in a significant decrease in PEPI (from 102±4.8 to 87.8±4.2; mean ± SEM;P〈0.01) and of PEP/LVET (from 0.56±0.05 to 0.45±0.05; mean ±SEM;P〈0.01) and in a significant increase of LVETI (from 237.6±5.6 to 253.3±5.2; mean ±SEM;P〈0.01) in group II. Heart rate increased significantly in both groups. Left ventricular end-diastolic dimension, also assessed by echocardiography, did not change in the eight studies performed. An increase in mean arterial pressure was found in three out of five newborns of group II and in one out of four patients in group I. It is concluded that dobutamine can improve cardiac performance in newborns with impaired left venfricular function. This effect is probably due to an improvement in myocardial contractility.
    Type of Medium: Electronic Resource
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  • 7
    ISSN: 1432-1076
    Keywords: Newborn ; Cardiac surgery ; Pulmonary hypertension ; Prostacyclin ; Nitric oxide
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract In a 3-week-old male newborn persistent suprasystemic pulmonary hypertension developed after surgical valvulotomy for a critical aortic valve stenosis. Because of a residual transvalvular pressure gradient of 35 mm Hg and postoperative left as well as right ventricular dysfunction, treatment with inhaled nitric oxide (NO) and intravenously infused prostacyclin (PGI2) was attempted. Low-dose inhaled NO and low dose PGI2 corrected severe pulmonary hypertension and led to an increase in cardiac output. Treatment with NO but not PGI2 was accompanied by a rise in PaO2 and systemic blood pressure. Interruption of NO administration led to a rapid increase in pulmonary arterial pressure to suprasystemic levels. With continued i.v. PGI2 and decreasing concentrations of NO, severe pulmonary hypertension resolved after a few days suggesting that a transient endothelial dysfunction was partially responsible for pulmonary vasoconstriction. NO inhalation appears to be an effective new tool in the treatment of severe pulmonary hypertension following cardiac surgery.
    Type of Medium: Electronic Resource
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  • 8
    Electronic Resource
    Electronic Resource
    Springer
    European journal of pediatrics 157 (1998), S. 689-690 
    ISSN: 1432-1076
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
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  • 9
    ISSN: 1433-0474
    Keywords: Schlüsselwörter Hochfrequenzoszillationsbeatmung ; Hämodynamik ; Ebstein-Anomalie ; Gaumenspalte ; Key words High-frequency oscillatory ventilation ; Cardiopulmonary interactions ; Ebstein’s anomaly ; Cleft palate
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Summary Background: We report on the unsuccessful attempt to put a young patient with Ebstein’s anomaly on conventional ventilation for maxillofacial surgery. Reduced pulmonary bloodflow and cardiac output were followed by arterial hypotension and reduction of oxygen saturation. Spontaneous breathing without positive pressure ventilation normalized of the hemodynamic situation. Operation: Two years later, using a high-frequency oscillatory ventilator (SensorMedics 3100A), with relatively constant intrathoracic pressures and avoidance of high inspiratory pressures, the patient was adequately ventilated and oxygenated during the operation.
    Notes: Zusammenfassung Hintergrund: Es wird über den zunächst nicht erfolgreichen Versuch der konventionellen Beatmung während eines kieferchirurgischen Eingriffs bei einer Patientin mit Ebstein-Anomalie berichtet. Verminderter pulmonaler Blutfluß und entsprechend verminderter linksventrikulärer Auswurf führten zu einer arteriellen Hypotonie mit Sauerstoffsättigungsabfall. Unter Spontanatmung normalisierte sich der kritische Zustand rasch. Operation: Der Einsatz eines Hochfrequenzoszillationsbeatmungsgeräts (SensorMedics 3100A) mit gleichbleibendem mittlerem Atemwegsdruck und Vermeiden inspiratorischer Spitzendrücke ermöglichte 2 Jahre später eine adäquate Ventilation und Oxygenierung der Patientin, so daß die Operation durchgeführt werden konnte.
    Type of Medium: Electronic Resource
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  • 10
    ISSN: 1433-0474
    Keywords: Schlüsselwörter Epikarde Elektroden ; Steroideluierende Elektroden ; Autocapture ; Frühgeborene ; Säugling ; Key words Epicardial pacing ; Steroid eluting electrodes ; Autocapture ; Infant
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Summary A small pulse-generator is important in prematures and young infants. Objectives: Analysis of our experience with the smallest currently available pacemaker in the pediatric age group. Patients and methods: We report about the pacemaker therapy in two premature babies with symptomatic complete congenital AV-block and about an 8 year old boy with congenital AV-block and palliation of complex congenital heart disease by total cavo pulmonary connection. The currently smallest pulse generator was implanted for the first time with a steroid eluting epicardial bipolar lead. Due to the ’autocapture algorithm’ a smaller battery can be used with the same life span as a normal sized pulse generator. Results: A stable capture threshold with a high amplitude of the evoked response signal and regular function of the ’autocapture’ algorithm was documented during a followup of up to 1 year. This algorithm has been used so far only with endocardial leads. Conclusion: This new combination seems promising for pacemaker therapy in small children.
    Notes: Zusammenfassung Fragestellung: Für Säuglinge und Frühgeborene ist eine geringe Größe des Schrittmacheraggregats besonders wichtig. Unsere bisherigen Erfahrungen mit dem kleinsten, z.Z. verfügbaren Pulsgenerator bei Kindern wurden analysiert und hier vorgestellt. Methode: Bei 2 Frühgeborenen mit symptomatischem kompletten AV-Block und einem 8jährigen Patienten mit kongenitalem AV-Block bei komplexen Vitium und Palliation mittels totaler kavopulmonaler Anastomose wurde der kleinste z.Z. verfügbare Pulsgenerator erstmals mit bipolaren, epikardialen steroideluierenden Elektroden implantiert. Dieser Schrittmacher arbeitet durch den Autocapture-Algorithmus besonders energiesparend, so daß trotz geringerer Batteriekapazität eine Laufzeit wie bei einem normal großen Aggregat erzielt werden kann. Ergebnisse: Bei einer niedrigen Reizschwelle und einer hohen Amplitude des evozierten Potentials fand sich eine normale Funktion des Autocapture-Algorithmus des Schrittmachers bei einer Nachbeobachtung bis zu 1 Jahr. Ein solches Aggregat wurde bislang nur mit endokardialen Elektroden eingesetzt. Schlußfolgerung: Diese Schrittmacher-Elektroden-Kombination erscheint als neues Therapiekonzept insbesondere für Säuglinge gut geeignet zu sein.
    Type of Medium: Electronic Resource
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