Description
Intensive Care Medicine was born in the year 1952: During the polio epidemic in Denmark the Danish anesthetist Björn Ibsen (1915-2007), who is meanwhile considered as the founder of intensive care medicine, ventilated for the first time a 12 years old girl with a severe poliomyelitis by positive pressure ventilation for a longer time, so that the first intensive care unit was founded in Kopenhagen 1952. The internal intensive care medicine has progressed rapidly since that time in the last few years like hardly any other medical field. On the basis of numerous studies new diagnostic and therapeutic approaches are continuously developed for the treatment of critically ill patients. The book “Internal intensive care medicine” has its origin in the “Compact course internal intensive care medicine”: This highly popular nationwide course is attended by colleagues from all over Germany, Austria and Switzerland for several years now. This course was primarily intended as an introduction for new staff in the intensive care unit, but it now comprises the entire internal intensive care medicine and is therefore also attended by a number of “old hands”. The special internal intensive care medicine is a challenge for everyone, not least because the mortality of internal intensive care patients is about three times as high as the mortality of surgical intensive care patients. About three quarters of all ventilated internal intensive care patients die! In Germany there is no interdisciplinary intensive care medicine. Only area-specific additional qualifications can be acquired (e.g. operational, internal or neurological intensive care medicine). De iure herefore it should be considered critically if it is reasonable that anaesthesiologists (e.g. with an additional qualification in operational intensive care medicine) assume the complette responsibility alone for the intensive care treatment of internal intensive care patients. In the case of a medical error the physician may be accused of contributory negligence and the hospital may be held liable for organizational faults (i.a. joint statement of the German Society for Internal Intensive Care Medicine [DGIIN] and the German Society for Internal Medicine (DGIM]: On the organization of internal intensive medicine at university clinics and hospitals). De facto, however, in my experience, it is already the case that the colleagues of anethesiology can very well take care of internist intensive care patients and do so (and sometimes even better than some internists). Especially in an interdisciplinary intensive care unit is is suitable to work together: Perhaps the anesthetist can occasionally support the internist with complex ventilation on the one hand, and on the other hand the internist may be helpful for the anesthesiologist in the management of complex cardiac arrhythmias. In about 50% of the cases a cardial disease leads to the admission of the patient to the intensive care unit and about 30% of all internal intensive care patients have a relevant cardial accompanying disease, so that often a cardiologist is appointed as head of an intensive care unit. Since 2014, the complex intensive care treatment (OPS-code 8-980) may only be accounted in the DRG-system (Diagnosis-Related System) by hospitals with the required structural requirements: This includes the continuous presence (24h) of a physician in the intensive care unit. The additional supervision of the intensive care unit by the doctor on duty who is also in charge of the emergency department and the peripheral units is not possible! Furthermore, the head of the intensive care unit has to have the additional qualification “intensive care”. The amount of the daily effort points (SAPS II, TISS 10) must also be determined. Since 2016, an in-house cardiac catheterization laboratory with 24h standby is also a prerequisite, which is a major problem for many clinics. Curiously enough this applies for the accounting of all diagnoses – not only for the cardiological ones. The reasons for this regulation are difficult to understand: One has to raise the question why a cardiac catheter is required for the treatment and therefore also for the accounting of, for example, a severe pneumonia or pancreatitis. The option of ECMO was also considered a prerequisite in 2020, but has not yet been officially implemented. Moreover, the acquisition of relevant skills is essential in the internal intensive care medicine. In a small (to medium-sized) clinic, where there are usually only three to four consultants for internal medicine, an internist should, at the latest when he becomes a consultant, fully master the relevant techniques and skills. The acquisition of an additional qualification is certainly very pleasant and graces the homepage of the hospital: Nevertheless, the consultant for internal medicine with the additional qualification “cardiology” is also expected to conduct an emergency gastroscopy with endoscopic hemostasis or an emergency-ERCP in case of a jammed concrement with cholangiogenic sepsis as well as the consultant for internal medicine with the additional designation “gastroenterology” is expected to master the attachment of a temporary pacemaker or the TEE. In a small clinic it is not possible to employ eight consultants for internal medicine with the respective additional qualification (cardiology, gastroenterology, pulmology, haematology etc.) which will then also have to do background tasks. All these tasks have to be performed by a single internist, because there is no other possibility. On the other hand, if you work in a large clinic (“center”), where there is a gastroenterologist for the endoscopic treatment of esophageal variceal bleeding , a cardiologist for the attachment of a temporary pacemaker, a pulmonologist for emergency bronchoscopy, a neurologist for the treatment of strokes or for the performance of lumbar punctures in case of suspected meningitis, a haematologist for the bone marrow puncture in case of suspected acute leukemia, an endocrinologist for the management of a ketoacidotic coma, an Addisonian crisis or a thyrotoxic crisis, an angiologist for emergency angiography, a radiologist for the assessment of an X-ray image etc., this is not absolutely necessary. Then it could be very useful to have at least the most important telephone numbers at hand and to complete the konsilzettel correctly. It should be noted that most of the physicians do not work in centers and the majority of intensive care patients is not treated in centers (94% of all patients are not treated in university clinics). This book is an attempt to present all aspects of internal intensive care medicine in a clear and concise manner. The content of this book is practice-oriented and intended primarily for clinicians. True to the motto “a picture is worth a thousand words”, an attempt was made to illustrate the topics with numerous pictures. This book can certainly not replace the practical training in intensive care units, but sometimes it can make it a little easier. Almost all of the treatment recommendations are based on studies so the reader should not be deprived of them (the knowledge of fundamental studies is also important for the examination of the optional internal intensive care training!). However, they are listed in separate boxes, so that they can be read by interested readers, but they are not absolutely necessary for the understanding of the text. An attempt was also made to implement the current guidelines (annotation to the zur S-Classification of guidelines [usual in Germany]: S1 [only recommendations of expert groups; lowest status]; S2e [evidence-based], S2k [consensus-based], S3 [evidence- and consensus-based; highest status]) and recommendations of the respective expert associations. The text is consciously and deliberately written in the nominal style since, in my personal opinion, learning is easier in the nominal style than in the verbal style. I hope that this book will facilitate the often difficult everyday life for many colleagues on the intensive care unit. At this point I would like to thank my faithful “allies” in the compact course on internal intensive care medicine, Dr. Josef Zach, Dr. Uli Tausch, Ulrich Follmann, Dr. Peter Roch, Dr. Franziska Rothfritz-Deutsch, Dr. Werner Kargl, Dr. Stefan GroĂźmann (also sincere thanks to him for the kind permission to use his wonderful schemata and drawings on the topic of ventilation), Dr. Carmen GroĂźmann, Dr. Horst Schleicher, Dr. Robert Dengler, Prof. Dr. Roland BĂĽttner and Mr. Alois Philipp and Mr. Peter Reiser for the provision of many images. A very special word of thanks goes to my clinical teachers of many years, Dr. Johannes Bumes, Ulrich Follmann, Dr. Josef Kraus and Dr. Bernhard SchieĂźl, my two instructors for cardiac catheterization PD Dr. Markus Resch and Prof. Dr. Dierk Endemann as well as to my parents. In Germany meanwhile the 11th edition of the book was published. The translation into English was started in March 2020 and was finished in April 2021. Regensburg, November, 2021 Volker Herold
