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Background: In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step.

Methods: A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes.

Results: Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated.

Conclusion: In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.

Patients with life-limiting or palliative illnesses represent a challenge for emergency departments because, despite the growing availability of specialized outpatient palliative care resources at home, patients often present during symptom exacerbations or when family caregivers become overwhelmed. Also, as life-limiting illnesses are frequently first diagnosed there and treatment goals are adjusted, it appears advantageous to establish early connections between emergency patients with palliative needs and palliative care resources. The objective of this study was to conduct a survey evaluating the availability of fundamental palliative care knowledge and palliative care structures in clinical acute and emergency medicine. For this purpose, an online survey was distributed via emergency medicine blogs, targeting physicians working in emergency departments. In total, 383 fully completed questionnaires were analyzed. It was found that the respondents often encounter patients with palliative needs. However, both outpatient and inpatient palliative resources are not universally accessible, and where, for instance, consultation services are available, there is a lack of consensus regarding the appropriate timing for their utilization. Structures for end of life care are largely in place, although time and personnel are often insufficiently available. There is an expressed interest in further education and training in palliative care. In conclusion, as emergency departments serve as the interface between outpatient and inpatient care, an interdisciplinary and holistic approach can be employed to lay the groundwork for ongoing palliative care, benefiting patients with palliative needs.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an endovascular procedure for aortic occlusion. The procedure can be used for temporary hemorrhage control as a bridge until surgical treatment for noncompressible abdominal or pelvic bleeding and to improve coronary and cerebral perfusion pressure during cardiopulmonary resuscitation. The prehospital administration is challenging and currently hardly possible in Germany. In the REBOA in bleeding and cardiac arrest in the prehospital care by helicopter emergency medical service (RIBCAP-HEMS) project, the prehospital use of REBOA will be tested in a feasibility study. This article describes the training course on the procedure in preparation for prehospital use, which was conducted before the start of the aforementioned feasibility study for the emergency physicians and paramedics (HEMS-TC) of the DRF Air Rescue Base in Halle (Saale). The course provided the necessary theoretical and practical skills to apply REBOA in the prehospital setting to patients in extremis in a safe, indications-conform and time-critical manner. The fact that all emergency physicians of the two air ambulances Christoph 84 and Christoph 85 in Halle are specialists in anesthesiology with corresponding experience in the placement of invasive arterial catheters proved to be advantageous. The training course was able to significantly improve the theoretical and practical abilities of the participants. The results of the currently ongoing study must show whether the procedure can be usefully integrated into the prehospital care of patients in extremis.

Background: Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies.

Objective: The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany.

Method: To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies.

Results: In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unkno

Background: Radial artery cannulation helps to maintain the stability of maternal hemodynamics and reduce complications; however, it is difficult for women with gestational hypertension. Subcutaneous nitroglycerin was found to improve the first attempt success rate of radial artery cannulation in pediatric patients. Therefore, this study evaluated the effect of subcutaneous nitroglycerin on the radial artery diameter and area, blood flow rate and the success rate of radial artery cannulation in women with pregnancy-induced hypertension.

Methods: A total of 94 women with gestational hypertension and risk of intraoperative bleeding undergoing cesarean section were identified and randomized into the subcutaneous nitroglycerin group and control group. The primary outcome was the success rate of left radial artery cannulation within 3 min after subcutaneous injecting (T2). The puncture time, number of attempts, the overall complications, and ultrasonographic measurements including radial artery diameter, cross-sectional area and depth were also recorded before subcutaneous injection (T1), 3 min after subcutaneous injection (T2) and immediately after radial artery cannulation (T3).

Results: The first attempt success rate of radial artery cannulation was significantly higher (97.9% vs. 76.6%, p = 0.004) and procedure time to success was significantly shorter (111 ± 18 s vs. 171 ± 70 s, p < 0.001) in the subcutaneous nitroglycerin group as compared to the control group. The subcutaneous nitroglycerin group also had a significantly less overall number of attempts as 1/2/3 attempts (n), 46/1/0 vs. 36/7/4 (p = 0.008). Compared with the control group, the diameter and cross-sectional area of radial artery increased significantly at the T2 and T3 points in the subcutaneous nitroglycerin group (p < 0.001), as well as percentage change of radial artery diameter and CSA. Vasospasm (6.4% vs. 31.9%; p = 0.003) was significantly lower in the subcutaneous nitroglycerin group; however, no difference was found in hematoma (2.1% vs. 12.8%; p = 0.111).

Conclusion: Subcutaneous nitroglycerin along with the routine local anesthetic preparation before radial artery cannulation increased the first attempt success rate of radial artery cannulation and decreased the overall number of cannulation attempts in women with gestational hypertension and risks of intraoperative bleeding undergoing cesarean section, it also decreased cannulation times and overall number of vasospasms.

Background: In a large proportion of patients admitted to the emergency department (ED), the initial main symptom is nonspecific. One possible reason for this, especially in older patients, may be adverse drug reactions (ADR) due to their frequent polypharmacy.

Aim: To illustrate the incidence of ADRs, the affected patient population including risk factors, and drug classes with ADRs leading to nonspecific symptoms. To provide practice recommendations for the management of ADRs in the ED.

Material and methods: Presentation of the pharmacological principles on ADRs, statistics of pharmacovigilance centers as well as original literature including experiences from clinical practice and own projects.

Results: In 10% of patients with nonspecific symptoms an ADR is responsible for presentation in the ED. In 60% of cases these ADRs are not correctly identified in the ED setting. A small number of drug classes are responsible for most of these referrals. Databases, risk stratification, clinical pharmacists, or clinical decision support systems are available to improve ADR identification and management. As these options are partly associated with considerable costs or the validation for German EDs is missing, a widespread application does not take place.

Conclusion: Correct identification of ADRs in patients with nonspecific symptoms in the ED is necessary to initiate adequate treatment. These ADRs are often overlooked because processes and tools for identification and management are not applied in the ED, leading to a lack of awareness. For high-risk patients in the ED, the focus should be on drug history, ideally considering patient-specific risk factors and specific drug classes.