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Kork F, Kleinwächter R, Weiss-Gerlach E, Broecker S, Pragst F, Wernecke KD, Spies C. Oral fluid testing for illicit substance use in preanaesthetic care. J Int Med Res 2012; 40:194-203. [PMID: 22429359 DOI: 10.1177/147323001204000120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Due to specific risks associated with illicit drug use, the preanaesthetic detection of illicit substances is essential. This prospective observational study evaluated oral fluid testing and self reporting of illicit drug use compared with confirmatory blood testing. METHODS Consecutively enrolled preanaesthetic and emergency room patients (n=939) completed a paper-based lifestyle questionnaire. An oral fluid sample was obtained and analysed for illicit substance use by a point-of-care testing device (Dräger Drugtest® 5000). Patients who tested positive by self reporting or oral fluid testing underwent confirmatory blood testing (n=117). RESULTS Self reporting revealed more overall illicit substance use and more users of cannabinoids, amphetamines, opioids, cocaine and benzodiazepines than oral fluid testing. Self reporting was more sensitive than blood testing for the detection of overall illicit substance use, and for use of cannabinoids and benzodiazepines. CONCLUSIONS Self reporting revealed higher rates of illicit substance use than oral fluid testing in preanaesthetic patients, and may lead to more interventions and more appropriately tailored treatment and anaesthesia compared with oral fluid testing.
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Kastrup M, Nolting MJ, Ahlborn R, Braun JP, Grubitzsch H, Wernecke KD, Spies C. An electronic tool for visual feedback to monitor the adherence to quality indicators in intensive care medicine. J Int Med Res 2012; 39:2187-200. [PMID: 22289534 DOI: 10.1177/147323001103900615] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Evidence-based medicine is often inadequately implemented in intensive care units (ICU); the aim of this study was to improve its implementation via a technical feedback system, using key performance indicators (KPI). The study evaluated 205 patients treated in a cardiac surgical ICU over a 6-month period (3 months before and 3 months after implementation of the feedback system). KPI adherence rates for sedation, delirium and pain monitoring, and completion of a weaning protocol before and after the implementation of the feedback system, were compared. Adherence rates for pain and delirium monitoring, and implementation of the weaning protocol, were significantly increased by the intervention. Adherence to KPIs for sedation, which were high at baseline, could not be further improved. Daily display of KPI implementation had a positive effect on adherence to standard operating procedures. Adherence to guidelines may be improved by using this feedback system as part of the clinical routine.
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Benhidjeb T, Gericke C, Spies C, Miller K, Schneider A, Müller F. [Perception of natural orifice surgery. Results of a survey of female physicians and nursing staff]. Chirurg 2012; 82:707-13. [PMID: 21431963 DOI: 10.1007/s00104-011-2079-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Natural orifice surgery (NOS) is now being elaborated with the aim to make abdominal surgery simpler and safer. In order to obtain women's perception of NOS and their willingness to consent to this type of approach a survey was conducted among female employees from surgical disciplines at the University Hospital Charité Berlin. MATERIAL AND METHODS A written description and information on minimally invasive surgery and the NOS concept were distributed among 500 female physicians and nursing staff along with a 14-item questionnaire. Of the staff members 118 participants completed the questionnaire anonymously. Data analysis was carried out using SPSS 16.0. RESULTS With regard to ovarectomy 55% of women surveyed indicated that they would prefer a transvaginal approach to standard laparoscopy (44%) or a transgastric approach (1%). When asked about preferred access for cholecystectomy only 31% would prefer the transvaginal method compared to 61% for the laparoscopic technique. Objections against the transvaginal access concerned the impact on a healthy sexual life and effects on fertility. Reasons for choosing NOS were no wound pain and no scar. CONCLUSION This survey shows that among the surveyed female medical employees the transvaginal approach is associated with concerns and fears but these are not justifiable, as the transvaginal access has been used for more than 100 years for gynecological purposes. There is a strong need for outcome data to enlighten female patients and to help guide physicians when talking to patients regarding NOS and the transvaginal approach.
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Spies C, Hijazi ZM. Indications, techniques and results of percutaneous patent foramen ovale closure. Minerva Cardioangiol 2012; 60:111-123. [PMID: 22322579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Patent foramen ovale (PFO) has been shown to be more prevalent in certain disease states, suggesting a potentially causative role in some patients with cryptogenic stroke, migraine headache or a number of other conditions. Percutaneous PFO closure has become a reasonable treatment option in a subset of those patients. Our objective is to review the possible indications of PFO closure. We further elucidate the technical aspects of PFO closure, provide an overview of the available devices and summarize results of PFO closure procedures.
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Viviano E, Renius M, Rückert JC, Bloch A, Meisel C, Harbeck-Seu A, Boemke W, Hensel M, Wernecke KD, Spies C. Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection. J Int Med Res 2012; 40:141-56. [DOI: 10.1177/147323001204000115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.
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Breuer JP, Langelotz C, Paquet P, Weimann A, Schwenk W, Bosse G, Spies C, Bauer H. [Perioperative nutrition - a nationwide web-based survey of German surgery departments]. Zentralbl Chir 2011; 138:622-9. [PMID: 22113589 DOI: 10.1055/s-0031-1283777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany. METHODS In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery. RESULTS From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents. CONCLUSION The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany.
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Neumann T, Neuner B, Weib-Gerlach E, Grittner U, Tempka A, Spies C. [Patients with minor injuries in a Berlin inner-city emergency room : substance misuse, residential area, and sociodemographics]. Med Klin Intensivmed Notfmed 2011; 106:117-24. [PMID: 22038636 DOI: 10.1007/s00063-011-0049-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 05/26/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this post hoc study was to evaluate the association of substance use disorders (SUD) and residential neighborhood affiliation in a group of patients with minor injuries presenting to an inner-city emergency room (ER) in Berlin. METHODS A total of 2,716 patients with minor injuries presenting to the ER were evaluated concerning alcohol use disorders (AUDIT, cut-off: males 8 points, females 5 points), smoking status, and illicit drug use in the past year. Information about residential area (zip code) and sociodemographics (paper-pencil questionnaire) were also obtained. RESULTS With respect to residential area, significant differences concerning SUD were identified: from the perspective of the inner-city ER, living close to the ER was associated with substance misuse. Here, alcohol use disorders (AUD), smokers, and illicit drug use were found more frequently compared to patients living in the periphery of the city. In addition, patients living close to the ER were more often unemployed, had a lower income, or were students. CONCLUSION There are differences in SUD with respect to residential area. However, in order to be able to draw reliable conclusions, an approach collecting representative data at the city district level as well as using a multicenter approach at the city ER level is necessary.
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Bosse G, Ngoli B, Leshabari MT, Külker R, Dämmrich T, Abels W, Breuer JP, Kersten R, Spies C. Quality of health care and the need for assessment. EAST AFRICAN JOURNAL OF PUBLIC HEALTH 2011; 8:199-204. [PMID: 23120956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE In many hospitals of developing countries quality of care is below the expected standard to maintain patient safety. In 2006, health care experts from Tanzania and Germany collaborated on a set of indicators to be used as a hospital performance assessment tool. The aim of this study was to introduce this tool and check its feasibility for use in a Tanzanian regional hospital. METHODS Within the hospital, independent observers assessed quantitatively structural quality and the performance of health care encounter using an itemized scale from 0 (0%) to 2 (100%) for each defined item. Outcome parameters were taken from the annual hospital report. In addition, semi-qualitative interviews with staff and patients were held to a) assess staff knowledge of the treatment guidelines published by the Tanzanian Ministry of Health and Social Welfare (MoHSW), b) assess attitudes and user motivation and c) authenticate the quantitative findings in a mixed-method triangulation approach. RESULTS Structural quality in maternity was at 75% of the expected standard, while process quality ranged from 36% (Care of the newborn with APGAR score < 4) to 47% (normal delivery procedure). Staff knowledge ranged between 64% and 87% with low motivation and commitment given as contributing factors. Outcome (maternal mortality) was 481/100,000 live births with an infant mortality rate of 10%. DISCUSSION The tool appeared to be feasible and effective in judging care quality. It provides a model for continuous quality improvement. Motivation of health care workers, a strong determinant of care process quality, might be improved by strengthening internal factors in health facilities. For conclusive validation, further studies using the tool must be conducted with larger numbers of institutions.
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Herz S, Puhl G, Spies C, Jörres D, Neuhaus P, von Heymann C. [Perioperative anesthesia management of extended partial liver resection. Pathophysiology of hepatic diseases and functional signs of hepatic failure]. Anaesthesist 2011; 60:103-17. [PMID: 21293838 DOI: 10.1007/s00101-011-1852-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy.
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Koenig T, Neumann C, Ocker T, Kramer S, Spies C, Schuster M. Estimating the time needed for induction of anaesthesia and its importance in balancing anaesthetists' and surgeons' waiting times around the start of surgery. Anaesthesia 2011; 66:556-62. [PMID: 21564042 DOI: 10.1111/j.1365-2044.2011.06661.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
After the anaesthetist has induced anaesthesia, it is desirable that the surgeon is present and ready to start surgery, otherwise the team needs to wait for the surgeon. From another perspective, however, the surgeon does not necessarily wish to be present from the start of induction, since that process can take a variable time and the surgeon might be otherwise occupied in productive activity rather than waiting for the patient to be ready. Waiting times in the morning can therefore be a source of constant friction between anaesthetists and surgeons. In this prospective study we used the data from 718 first cases of the day, during a 4-week study period at two university hospitals, to develop a simple spreadsheet-based method to analyse the interaction of anaesthesia and surgical start time, anaesthesia technique and the probability of waiting time for anaesthetist or surgeon, respectively. This method can be used to determine the best surgical or anaesthesia start time for each case, so that the waiting time for anaesthetists and surgeons can be minimised.
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Tafelski S, Nachtigall I, Deja M, Tamarkin A, Trefzer T, Halle E, Wernecke KD, Spies C. Computer-assisted decision support for changing practice in severe sepsis and septic shock. J Int Med Res 2011; 38:1605-16. [PMID: 21309474 DOI: 10.1177/147323001003800505] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Computer-assisted decision support systems (CDSS) are designed to improve infection management. The aim of this prospective, clinical pre- and post-intervention study was to investigate the influence of CDSS on infection management of severe sepsis and septic shock in intensive care units (ICUs). Data were collected for a total of 180 days during two study periods in 2006 and 2007. Of the 186 patients with severe sepsis or septic shock, 62 were stratified into a low adherence to infection management standards group (LAG) and 124 were stratified into a high adherence group (HAG). ICU mortality was significantly increased in LAG versus HAG patients (Kaplan-Meier analysis). Following CDSS implementation, adherence to standards increased significantly by 35%, paralleled with improved diagnostics, more antibiotic-free days and a shortened time until antibiotics were administered. In conclusion, adherence to infection standards is beneficial for patients with severe sepsis or septic shock and CDSS is a useful tool to aid adherence.
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Heymann A, Radtke F, Schiemann A, Lütz A, MacGuill M, Wernecke KD, Spies C. Delayed treatment of delirium increases mortality rate in intensive care unit patients. J Int Med Res 2011; 38:1584-95. [PMID: 21309472 DOI: 10.1177/147323001003800503] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS >7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.
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Foehre B, von Heymann C, Deja M, Lange LF, Krampe H, Wernecke KD, Spies C. Central area for induction of anesthesia and job satisfaction. ACTA ANAESTHESIOLOGICA BELGICA 2011; 62:15-21. [PMID: 21612141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A central area for induction of anesthesia (CAIA) is supposed to optimize processes of preoperative patient preparation for anesthesia. The purpose of this study was to assess whether the separation of the anesthesia process into anesthesia induction and anesthesia maintenance is associated with residents' job satisfaction. The central area for induction of anesthesia model (CAIA model) was prospectively compared to the conventional model of anesthesia being induced, maintained and ended by the same anesthetist. Quality of senior staff supervision for each day as well as workday satisfaction was additionally graded by a Likert-scale. More than 80% of residents considered their workday as satisfying or very satisfying, regardless of the model applied. Furthermore, work day satisfaction was significantly associated with the quality of supervision provided by the teaching staff. It was concluded that time and attention provided by the teaching staff rather than the anesthesia organisational model were the major determinants of workday satisfaction.
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller A, Heringlake M, Kastrup M, Kroener A, Loer S, Marggraf G, Markewitz A, Reuter D, Schmitt D, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0790-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Spies C, Cao QL, Hijazi ZM. Transcatheter closure of congenital and acquired septal defects. Eur Heart J Suppl 2010. [DOI: 10.1093/eurheartj/suq006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Breuer J, Bosse G, Spies C. Reply. Acta Anaesthesiol Scand 2010. [DOI: 10.1111/j.1399-6576.2010.02288.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. [Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)]. Anaesthesist 2010; 59:347-70. [PMID: 20414762 DOI: 10.1007/s00101-010-1719-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)). GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc14. [PMID: 20628653 PMCID: PMC2899863 DOI: 10.3205/000103] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Indexed: 12/16/2022]
Abstract
Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller AR, Heringlake M, Kastrup M, Kroener A, Loer SA, Marggraf G, Markewitz A, Reuter D, Schmitt DV, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc12. [PMID: 20577643 PMCID: PMC2890209 DOI: 10.3205/000101] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Indexed: 01/20/2023]
Abstract
Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).
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Göktas O, Fleiner F, Spies C, Krieg H, Bauer K, Sedlmaier B. [Process optimization in ENT: clinical pathways and central induction area]. HNO 2010; 58:142-50. [PMID: 20111916 DOI: 10.1007/s00106-009-2031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Owing to the rising costs in the health care system, it is now important to optimize processes through standardization and process consolidation. A lack of process consolidation in this area of operation or overly long durations of stay of patients in the hospital can lead to increased costs for the ENT department. The aim of this study was to examine whether process optimization could be achieved through close interdisciplinary networking with clinical pathways and central induction (CI). MATERIAL AND METHODOLOGY In the 1-year periods before and after the implementation of CI, turnover times in the ENT department were retrospectively examined and 2,433 patients from the entire operative ENT spectrum were included. The average durations of stay before and after the implementation of the "septoplasty" pathway were additionally evaluated. RESULTS ENT turnover times were significantly reduced after the introduction of CI. In comparison to the conventional anaesthesia process, the turnover times using CI were on average 10 min shorter. Furthermore, since the introduction of pathways, the duration of stay for ENT patients could be significantly reduced while simultaneously maintaining the quality of care. This process was statistically evaluated using septoplasty in nasal surgery as a typical example and the duration of stay was reduced from 5.85 days to 4.32 (a reduction of 26%) or 3.55 days (a reduction of 34%). CONCLUSIONS The combination of CI and pathways is a suitable means to increase the clinical and economic effectiveness even when the new case-based flat-rate system is taken into consideration.
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Sawatzki T, Bauer K, Stufler M, Spies C, Schuster M. [Splitting of supplemental revenues in intensive care medicine]. Anaesthesist 2010; 58:1035-40. [PMID: 19756333 DOI: 10.1007/s00101-009-1617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs.
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Breuer JP, Bosse G, Seifert S, Prochnow L, Martin J, Schleppers A, Geldner G, Soreide E, Spies C. Pre-operative fasting: a nationwide survey of German anaesthesia departments. Acta Anaesthesiol Scand 2010; 54:313-20. [PMID: 19764905 DOI: 10.1111/j.1399-6576.2009.02123.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Shorter pre-operative fasting improves clinical outcome without an increased risk. Since October 2004, German Anaesthesiology Societies have officially recommended a fast of 2 h for clear fluids and 6 h for solid food before elective surgery. We conducted a nationwide survey to evaluate the current clinical practice in Germany. METHODS Between July 2006 and January 2007, standardized questionnaires were mailed to 3751 Anaesthesiology Society members in leading positions requesting anonymous response. RESULTS The overall response rate was 66% (n=2418). Of those, 2148 (92%) claimed familiarity with the new guidelines. About a third (n=806, 34%) reported full adherence to the new recommendations, whereas 1043 (45%) reported an eased fasting practice. Traditional Nil per os after midnight was still recommended by 157 (7%). Commonest reasons reported for adopting the new guidelines were: 'improved pre-operative comfort' (84%), and 'increased patient satisfaction' (83%); reasons against were: 'low flexibility in operation room management' (19%), and 'increased risk of aspiration' (13%). CONCLUSION Despite the apparent understanding of the benefits from reduced pre-operative fasting, full implementation of the guidelines remains poor in German anaesthesiology departments.
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Viviano E, Renius M, Rückert J, Bloch A, Meisel C, Harbeck-Seu A, Boemke W, Hensel M, Wernecke K, Spies C. Selective neurogenic blockades and perioperative immune reactivity in patients undergoing lung resection. Crit Care 2010. [PMCID: PMC2933982 DOI: 10.1186/cc8711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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74
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Wittkowski U, Spies C, Sander M, Erb J, Feldheiser A, von Heymann C. [Haemodynamic monitoring in the perioperative phase. Available systems, practical application and clinical data]. Anaesthesist 2009; 58:764-78, 780-6. [PMID: 19669105 DOI: 10.1007/s00101-009-1590-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed.
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Hampel C, Schenk M, Göbel H, Gralow I, Grüsser SM, Jellinek C, Ernst G, Hermanns K, Gölz J, Poser W, Strumpf M, Neugebauer EAM, Spies C. [Pain therapy in addicted patients]. Schmerz 2009; 20:445-57; quiz 458-9. [PMID: 16955296 DOI: 10.1007/s00482-006-0491-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2003] [Accepted: 01/02/2004] [Indexed: 10/24/2022]
Abstract
Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.
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Eggers V, Kopp I, Spies C. [Do we need a reform in the development of guidelines? A commentary]. Anaesthesist 2009; 58:728-30. [PMID: 19471896 DOI: 10.1007/s00101-009-1562-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Guidelines serve the decision-making process in medicine and must, therefore, be of high methodical and professional quality and must not be influenced by financial or commercial interests. Sniderman and Furberg have demanded that the process of guideline-making must be fundamentally reassessed and optimized for American circumstances. Their demands are critically assessed and commented on for the development of guidelines of the German Society for Anesthesiology and Intensive Care Medicine.
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Ramme A, Schmidt M, Breuer JP, Miescke K, Radtke F, Spies C. P84 Length of hospital stay for elderly patients after cancer surgery is depending on ASA state and length of surgery but not on age. Crit Rev Oncol Hematol 2009. [DOI: 10.1016/s1040-8428(09)70122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Schmidt M, Breuer JP, Ramme A, Miescke K, Spies C. F17 Preoperative risk stratification and postoperative management in elderly cancer patients. Crit Rev Oncol Hematol 2009. [DOI: 10.1016/s1040-8428(09)70019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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79
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von Dossow V, Moshirzadeh M, Kastrup M, Wernecke KD, Konertz W, Spies C. Performance of the A-line Autoregressive Index (AAI) and of the Bispectral Index (BIS) at assessing depth of short-term sedation following cardiac surgery. J Int Med Res 2009; 37:611-20. [PMID: 19589243 DOI: 10.1177/147323000903700303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study evaluated the correlation and agreement between the Bispectral Index (BIS) or A-line Autoregressive Index (AAI) and a clinical scoring system, the Ramsay Sedation Scale (RSS), in 40 patients after elective cardiac surgery and admission to the intensive care unit. All patients received sedation with propofol according to the study protocol. BIS, AAI and RSS were documented at two different levels of sedation: deep sedation RSS 4 - 6; and slight sedation/extubation RSS 2 - 3. Both the BIS and AAI agreed well with the RSS (eta-coefficients of 0.902 and 0.836, respectively, for mean overall RSS stages). The systems agreed well among each other (overall intra-class correlations of 0.670 for consistency and 0.676 for absolute agreement). There was significant discrimination between RSS 2 - 3 and RSS 4 - 6 with BIS and AAI (BIS mean difference of 24.73, 95% confidence intervals [CI] 21.08 - 28.37; AAI mean difference of 20.90, 95% CI 14.64 - 27.16). In conclusion, BIS and AAI correlated well with RSS overall and also at different levels of sedation.
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Vargas Hein O, Staegemann M, Wagner D, von Heymann C, Martin M, Morgera S, Spies C. Torsemide Versus Furosemide After Continuous Renal Replacement Therapy Due to Acute Renal Failure in Cardiac Surgery Patients. Ren Fail 2009; 27:385-92. [PMID: 16060124 DOI: 10.1081/jdi-65298] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diuretic therapy in ARF (acute renal failure) is mainly done with loop diuretics, first of all furosemide. Torsemide has a longer duration of action and does not accumulate in renal failure. In chronic and acute renal failure, both diuretics have been effectively applied, with a more pronounced diuretic effect for torsemide. In this study, the effects of torsemide versus furosemide on renal function in cardiac surgery patients recovering from ARF after continuous renal replacement therapy (CRRT) were studied. Twenty-nine critically ill patients admitted to an intensive care unit at a university teaching hospital after cardiac surgery recovering from ARF after CRRT were included in this prospective, controlled, single-center, open-labeled, randomized clinical trial. Inclusion criteria were urine output >0.5 mL/kg/h over 6 h under CRRT. Torsemide and furosemide dosages were adjusted with the target urine output being 0.8-1.5 mL/kg/h. Hemodynamic data, urine output, volume balance, serum creatinine clearance, electrolytes, blood urea nitrogen, serum creatinine, renin, and aldosterone concentrations were measured. Fourteen patients were included in the furosemide group and 15 patients in the torsemide group. Dosages of 29 (0-160) mg torsemide and a dosage of 60 (0-240) mg furosemide were given every 6 h in each group, respectively. The dosage given at the end of the study decreased significantly in furosemide and torsemide treated patients. Urine output, 24 h balance, and serum creatinine clearance did not differ significantly between groups. Urine output decreased in both groups, mostly dose-dependent in the torsemide group. The intragroup comparison of the first time-interval after inclusion with the last time-interval showed a significant increase in serum creatinine and blood urea nitrogen in the furosemide group. Renin and aldosterone concentrations did not show significant differences. In conclusion, torsemide and furosemide were effective in increasing urine output. Torsemide might show a better dose-dependent diuretic effect in ARF patients after CRRT treatment. Serum creatinine and blood urea nitrogen elimination were less pronounced in the furosemide group.
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Neuner B, Weiss-Gerlach E, Miller P, Martus P, Hesse D, Spies C. Emergency department-initiated tobacco control: a randomised controlled trial in an inner city university hospital. Tob Control 2009; 18:283-93. [PMID: 19528043 PMCID: PMC2709908 DOI: 10.1136/tc.2008.028753] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: Emergency department (ED) patients show high smoking rates. The effects of ED-initiated tobacco control (ETC) on 7-day abstinence at 12 months were investigated. Methods: A randomised controlled intention-to-treat trial (trials registry no.: ISRCTN41527831) was conducted with 1044 patients in an urban ED. ETC consisted of on-site counselling plus up to four telephone booster sessions. Controls received usual care. Analysis was by logistic regression. Results: In all, 630 (60.7%) participants were males, the median age was 30 years (range 18–81) and the median smoking intensity was 15 (range 1–60) cigarettes per day. Overall, 580 study participants (55.6%) were unmotivated, 331 (31.7%) were ambivalent and 133 (12.7%) were motivated smokers. ETC (median time 30 (range 1–99) min) was administered to 472 (91.7% out of 515) randomised study participants. At follow-up, 685 study participants (65.6% of 1044) could be contacted. In the ETC group, 73 out of 515 (14.2%) in the ETC group were abstinent, whereas 60 out of 529 (11.3%) controls were abstinent (OR adjusted for age and gender = 1.31 (95% CI 0.91 to 1.89, p = 0.15). Stratified for motivation to change behaviour, the adjusted ORs for ETC versus usual care were OR = 1.00 (95% CI 0.57 to 1.76) in unmotivated smokers, respectively OR = 1.37 (95% CI 0.73 to 2.58) in ambivalent smokers and OR = 2.19 (95% CI 0.98 to 4.89) in motivated smokers, p for trend = 0.29. Conclusions: ETC, in the form of on-site counselling with up to four telephone booster sessions, showed no overall effect on tobacco abstinence after 12 months. A non-significant trend for a better performance of ETC in more motivated smokers was observed.
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Hasenberg T, Keese M, Längle F, Reibenwein B, Schindler K, Herold A, Beck G, Post S, Jauch KW, Spies C, Schwenk W, Shang E. 'Fast-track' colonic surgery in Austria and Germany--results from the survey on patterns in current perioperative practice. Colorectal Dis 2009; 11:162-7. [PMID: 18462237 DOI: 10.1111/j.1463-1318.2008.01559.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE 'Fast-track' rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Despite this evidence, there is no information on the acceptance and utilization of these concepts among the entirety of Austrian and German surgeons. METHOD In 2006, a questionnaire concerning perioperative routines in elective, open colonic resection was sent to the chief surgeons of 1270 German and 120 Austrian surgical centres. RESULTS The response rate was 63% in Austria (76 centres) and 30% in Germany (385 centres). Mechanical bowel preparation is used by the majority (Austria, 91%; Germany, 94%); the vertical incision is the standard method of approach to the abdomen in Austria (79%) and Germany (83%), nasogastric decompression tubes are rarely used, one-third of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centres allow the intake of clear fluids on the day of surgery and one-fifth offer solid food on that day. Epidural analgesia is used in three-fourths of the institutions. CONCLUSION Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine in Austria and Germany.
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Steinhilp L, Bubser F, Wiesener S, Spies C, Boschmann M, Schütz T, Weber-Carstens S. Bioelectrical impedance analysis in ICU patients. Crit Care 2009. [PMCID: PMC4084115 DOI: 10.1186/cc7393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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84
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Neumann T, Goldmann A, Breuer JP, Spies C. Alkoholentzugsbehandlung in der somatischen Medizin. SUCHTTHERAPIE 2008. [DOI: 10.1055/s-0028-1117334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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85
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Hommel M, Deja M, von Dossow V, Diemel K, Heidenhain C, Spies C, Weber-Carstens S. Bronchial fistulae in ARDS patients: management with an extracorporeal lung assist device. Eur Respir J 2008; 32:1652-5. [DOI: 10.1183/09031936.00021008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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86
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Gregor JI, Schwenk W, Mall J, Kilian M, Spies C, Bloch A, Müller JM, Rückert JC. ["Fast-track" rehabilitation in thoracic surgery. First experiences with a multimodal, interdisciplinary, and proven perioperative treatment course]. Chirurg 2008; 79:657-64. [PMID: 18449517 DOI: 10.1007/s00104-008-1533-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES "Fast-track" rehabilitation is a multimodal perioperative treatment concept for accelerating postoperative recovery which has been already used successfully in visceral surgery. Of its use in thoracic surgery however, almost no data exist and the relevance of this concept for pulmonary operations is unknown. PATIENTS AND METHODS In this prospective study we examined a new perioperative fast-track treatment concept for thoracic surgery and evaluated the results. This program employs detailed information of patients, intensive perioperative respiratory therapy, thoracic peridural analgesia, forced mobilization, and an early start of postoperative normal food intake. RESULTS Fifty consecutive patients with benign or malignant diseases of the lung aged an average of 64 years (range 22-78) were operated on thoracoscopically (n=15) or with thoracotomy (n=35) and treated perioperatively using the fast-track program. All patients were mobilized beginning 4 h postoperatively and had normal food. The incidence of general postoperative complications was 0% in this study. Postoperative stay lasted 4.5 days (range 1.5-28.5). There was no increase in surgical complications, and 6% of the patients were readmitted. The patients' acceptance of this concept was high. CONCLUSION Fast-track rehabilitation resulted in a decreased rate of general complications and accelerated rehabilitation in thoracic surgery.
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Spies C, Weisskopf M, Ohnsorge JAK. [Intraspinal echinococcosis within the lumbar spine of an 18-year-old male patient]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2008; 146:463-7. [PMID: 18704842 DOI: 10.1055/s-2008-1038543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Echinococcosis of human pathogenetic relevance is a very rare disease in Europe. The vertebral manifestation of the latter zoonosis constitutes one percent of all cases. Intraspinal echinococcosis appears worldwide just sporadically, whereas extradurally located cysts are identified more often than intradurally located ones. The diagnostic and specific therapeutic consequences of this very seldom entity are discussed based on a case report.
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Rundshagen I, Mast J, Mueller N, Pragst F, Spies C, Cortina K. Nervus medianus evoked potentials and bispectral index during repeated transitions from consciousness to unconsciousness. Br J Anaesth 2008; 101:366-73. [PMID: 18587138 DOI: 10.1093/bja/aen186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We investigated the relationship between median nerve somatosensory evoked potentials (SSEPs) and the bispectral index (BIS) during alternating periods of consciousness and propofol-induced unconsciousness. METHODS Loss of consciousness (LOC) was repetitively induced by bolus injections of propofol in 24 patients undergoing elective surgery in spinal anaesthesia. SSEP and the BIS were recorded during LOC and recovery of consciousness (ROC). The level of consciousness was clinically assessed by the observer's assessment of alertness/sedation scale. Propofol venous plasma concentrations were measured simultaneously. RESULTS At LOC, all SSEPs latency components were prolonged (P<0.001), whereas amplitudes of the components > or = 45 ms were smaller (P=0.008) and the BIS values were lower (P<0.001). None of the EEG variables regained baseline levels during ROC. Regression analyses revealed that the SSEP components (five latencies and five amplitudes) explained 33% of the variance when predicting ROC; the BIS explained 12%. The combination of SSEP and BIS explained 37% of variance in this patient sample. Propofol venous plasma concentration was 1.2 (0.8) microg ml(-1) during LOC and 0.4 (0.5) microg ml(-1) during ROC. CONCLUSIONS The present results indicate the usefulness of combining variables of the evoked and spontaneous EEG to measure different levels of consciousness, because the SSEP provide additional information beyond the BIS. Inter-individual variability of all the EEG variables limits their predictive potency of ROC after propofol infusion.
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Deja M, Hommel M, Weber-Carstens S, Moss M, von Dossow V, Sander M, Pille C, Spies C. Evidence-based therapy of severe acute respiratory distress syndrome: an algorithm-guided approach. J Int Med Res 2008; 36:211-21. [PMID: 18380929 DOI: 10.1177/147323000803600201] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Despite considerable research and constantly emerging treatment modalities, the mortality associated with acute respiratory distress syndrome (ARDS) has remained virtually unchanged over the last decade. Clinical studies have been unable to show a reduction in mortality for most therapeutic interventions except for low tidal volume ventilation. Failure to prove a mortality benefit might be a result of the varying severity of ARDS in the patients studied. Nevertheless, positive responses to single supportive measures (inhaled nitric oxide, prone positioning and extracorporeal membrane oxygenation) have been demonstrated in multiple trials. Criteria for administration, weaning and discontinuation of these supportive interventions have never been described in detail. In this context, implementation of an evidence-based algorithm might facilitate clinical management of severe ARDS. This review summarizes the current evidence base and proposes a new treatment algorithm that aims to prioritize the administration of advanced strategies in a multimodal approach for ARDS.
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Nachtigall I, Deja M, Tafelski S, Tamarkin A, Schaller K, Halle E, Gastmeier P, Wernecke KD, Bauer T, Kastrup M, Spies C. Adherence to Standard Operating Procedures is Crucial for Intensive Care Unit Survival of Elderly Patients. J Int Med Res 2008; 36:438-59. [DOI: 10.1177/147323000803600308] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Elderly patients account for 42–52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients ( n = 228) aged ≤ 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and ≤ 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG ( n = 137) had significantly reduced mortality compared with LAG patients ( n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.
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Radtke F, Franck M, Lorenz M, Seeling M, Spies C. Postoperative delirium is associated with intraoperative opioid use. Eur J Anaesthesiol 2008. [DOI: 10.1097/00003643-200805001-00308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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92
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von Heymann C, Rosenthal C, Volk T, Spies C. [Bedside thrombelastography]. Anaesthesist 2008; 56:1286-7; author reply 1287-8. [PMID: 17975713 DOI: 10.1007/s00101-007-1278-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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93
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Neumann T, Neuner B, Weiss-Gerlach E, Spies C. Complaints about sleep in trauma patients in an emergency department in respect to alcohol use. Alcohol Alcohol 2008; 43:305-13. [DOI: 10.1093/alcalc/agn007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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94
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Hasenberg T, Rittler P, Post S, Jauch KW, Senkal M, Spies C, Schwenk W, Shang E. [A survey of perioperative therapy for elective colon resection in Germany, 2006]. Chirurg 2008; 78:818-26. [PMID: 17516040 DOI: 10.1007/s00104-007-1354-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Despite the evidence that fast-track concepts in colon surgery lead to an enhanced recovery rate, there is no information on the prevalence and utilization of such programs in Germany. METHODS Based on a conventional sigmoid resection, we asked 1,270 surgical departments in Germany to describe their standard surgical procedures in a questionnaire. RESULTS The response rate was 385 (30.31%). A total of 96% use a bowel preparation, 83% a vertical incision, 10% use a nasogastric decompression for longer then 1 day, 34% avoid intra-abdominal drains, 51% allow clear fluids on the day of surgery, 13% offer solid food on the first day after surgery, 75% use epidural analgesia and 47% discharge the patients by the seventh day after surgery. CONCLUSION Although there is an evident benefit using fast-track concepts, they are not yet in wide use as a standard procedure. Further efforts have to be made to ensure that the majority of patients will benefit from these concepts.
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Spies C, Schnürer S, Gotterbarm T, Breusch S. Tierexperimentelle Untersuchung des Knochenersatzstoffs Ostim™ im knöchernen Lager des Göttinger Miniaturschweins. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2008; 146:64-9. [DOI: 10.1055/s-2007-965756] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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96
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Neumann T, Helander A, Dahl H, Holzmann T, Neuner B, Weiss-Gerlach E, Muller C, Spies C. Value of Ethyl Glucuronide in Plasma as a Biomarker for Recent Alcohol Consumption in the Emergency Room. Alcohol Alcohol 2008; 43:431-5. [DOI: 10.1093/alcalc/agn035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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97
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Bosse G, Schröder T, von Heymann C, Spies C. [Berliner Simulations training (BeST)--the concept of anesthesia simulation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 42:740-4. [PMID: 17968772 DOI: 10.1055/s-2007-993024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Within recent years patient safety has become increasingly important. Within US hospitals more than 98.000 deaths have been reported annually due to medical errors, more than 80 % due to preventable mistakes. To improve patient safety it is therefore important to develop training tools, which center on the complexity of preventable mistakes, analyze underlying factors and eventually train to deal with them. Since the Berlin Simulation training was founded in 1997 it focused on the internationally accepted "global approach" based on three phases of briefing, simulation and debriefing. It concentrates on the reasons of preventable mistakes and their interaction. Problem solving strategies and the application of NTS ( planing, management, teamwork and communication) and TS (sound scientific knowledge and abilities) are practiced under the supervision of experienced trainers. The goal is to provide insight into the cascades of error and terminate them, to ultimately increase patient safety and provider satisfaction.
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Rundshagen I, Hardt T, Cortina K, Pragst F, Fritzsche T, Spies C. Narcotrend-assisted propofol/remifentanil anaesthesia vs clinical practice: does it make a difference? Br J Anaesth 2007; 99:686-93. [PMID: 17704091 DOI: 10.1093/bja/aem231] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Narcotrend is a computer-based EEG monitor designed to measure the depth of anaesthesia. The aim of the present study is to test the hypothesis that the intraoperative level of anaesthetic depth differs if decision-making is guided by Narcotrend monitoring or not. METHODS Forty-eight patients undergoing elective surgery were randomized to receive a Narcotrend-controlled propofol/remifentanil anaesthetic regimen or standard clinical practice. In the EEG group, anaesthesia was adjusted to achieve a Narcotrend level of D2-E0, which is recommended for moderate to deep anaesthetic depth for surgery. EEG values were recorded continuously every 20 s in both groups. Depending on data distribution, group comparisons of the EEG parameters, propofol plasma concentration, and recovery characteristics were performed by analysis of variance for repeated measurements or non-parametric statistics. RESULTS About 62 (sd 29)% of the Narcotrend values were within the target level in the EEG group during maintenance of anaesthesia; this was true for 64 (26)% of the data in the non-EEG group. The variance of the Narcotrend data was significantly lower in the EEG group compared with the non-EEG group [median: 0.4 (range: 3.5) vs 0.6 (2.5); P = 0.048]. There was no difference in propofol or remifentanil dosage, propofol plasma concentrations, and time for extubation. Ten minutes after extubation, visual analogue scores for nausea indicated a lower incidence in the Narcotrend group [7 (15) vs 24 (34); P = 0.005]. CONCLUSIONS Guidance of anaesthesia with the Narcotrend-monitor leads to fewer deviations from a defined target than clinical assessment of anaesthetic depth only. This results in lower scores of nausea in the immediate period after anaesthesia.
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Hasenberg T, Niedergethmann M, Rittler P, Post S, Jauch KW, Senkal M, Spies C, Schwenk W, Shang E. Elektive Kolonresektionen in Deutschland. Anaesthesist 2007; 56:1223-6, 1228-30. [PMID: 17882388 DOI: 10.1007/s00101-007-1259-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany. METHODS In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection. RESULTS The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia. CONCLUSION In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Göpfert M, Gogarten W, Grosse J, Heller A, Heringlake M, Kastrup M, Kröner A, Loer S, Marggraf G, Markewitz A, Reuter M, Schmitt DV, Schirmer U, Wiesenack C, Zwissler B, Spies C. [Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. Thorac Cardiovasc Surg 2007; 55:130-48. [PMID: 17377871 DOI: 10.1055/s-2007-964939] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).
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