The future of intensive care: the study of the microcirculation will help to guide our therapies

The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is happening in the microcirculation of organs, which prevents them from achieving an additional degree of individualization of the hemodynamic resuscitation at tissue level. Indeed, clinicians never know whether optimization of the microcirculation and tissue oxygenation is actually achieved after macrovascular hemodynamic optimization. The challenge for the future is to have noninvasive, easy-to-use equipment that allows reliable assessment and immediate quantitative analysis of the microcirculation at the bedside. There are different methods for assessing the microcirculation at the bedside; all have strengths and challenges. The use of automated analysis and the future possibility of introducing artificial intelligence into analysis software could eliminate observer bias and provide guidance on microvascular-targeted treatment options. In addition, to gain caregiver confidence and support for the need to monitor the microcirculation, it is necessary to demonstrate that incorporating microcirculation analysis into the reasoning guiding hemodynamic resuscitation prevents organ dysfunction and improves the outcome of critically ill patients.

[Isolation precautions, diagnostics and organization in German emergency departments during the 2020 COVID-19 pandemic]

BACKGROUND

Since the beginning of the coronavirus disease 19 (COVID-19) pandemic, German emergency departments (ED) have been working in the area of conflict between high case load and demanding hygienic and organizational challenges. The aim of this study was to gain an overview of the current status of isolation measures, diagnostics and patient allocation of suspected COVID-19 cases.

METHODS

Supported by the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) we invited leading ED physicians to answer an anonymous online survey regarding isolation measures, diagnostics and organization in emergency rooms during the COVID-19 pandemic.

RESULTS

A total of 139 responders from all federal states and all levels of care took part in the survey. Standard operating procedures on COVID-19 exist in almost all participating EDs, although concrete measures to end isolation are often missing. Most EDs screen patients for the "classic" COVID-19 symptoms such as fever, respiratory symptoms or contact to positive subjects in a standardized fashion, although the threshold for prophylactic isolation varies greatly. The individual swab-testing and allocation strategies vary relatively strongly. Less than half of all EDs have a separate procedure for uninterrogatable patients (e.g. major trauma). In about 8% of suspected cases, COVID-19-specific thoracic computed tomography is performed in the ED.

CONCLUSION

The current survey shows that the German EDs are well positioned for the moment, even though the isolation threshold is too high at some locations. In view of a possible increase in the number of cases during the winter season, a more precise differentiation of the previous recommendations of the Robert Koch Institute, especially for emergency admission patients, would be desirable. In this context, we propose a universal algorithm for the (de-)isolation of suspect cases in the ED.