Der Anaesthesist [journal]
- [Erratum to: Dexmedetomidine in the treatment of acute alcohol withdrawal delirium]. [PUBLISHED ERRATUM]
- Anaesthesist 2016 Aug 23.
- [PUBLISHED ERRATUM]
- Anaesthesist 2016 Aug 9.
- [Preclinical fibrinolysis in patients with ST-segment elevation myocardial infarction in a rural region]. [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- Anaesthesist 2016 Aug 8.
In the current guidelines for the treatment of patients with ST-segment elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) recommends preclinical fibrinolysis as a reperfusion therapy if, due to long transportation times, no cardiac catheterisation is available within 90-120 min. However, there is little remaining in-depth expertise in this method because fibrinolysis is presently only rarely indicated.In a rural area in southwestern Germany, where an emergency primary percutaneous coronary intervention was not routinely available within 90-120 min, 156 STEMI patients underwent fibrinolysis with the plasminogen activator reteplase, performed by trained emergency physicians. The practicality of the treatment, as well as complications and the mortality of the patients in the preclinical phase until arrival at the hospital, were retrospectively studied.The mean time from onset of the symptoms to first medical contact was 114 ± 116 min. The mean interval to the start of fibrinolysis of 13.5 ± 6.4 min was within the 30 min mandated by the ESC. Patients with inferior STEMI represented the largest subgroup. Occurring in 39 cases (25 %), complications due to infarction were relatively common during the prehospital phase, including 15 cases (9.6 %) of cardiogenic shock, but in all cases the complications were manageable. No patient died before arrival at the hospital. As lysis-associated adverse effects, merely two uncomplicated mucosal haemorrhages and one case of mild allergic skin reactions were seen.In emergency situations with long transportation times to the nearest suitable cardiac catheterisation laboratory, preclinical fibrinolysis in STEMI still represents a workable method. Success of this strategy requires particularly strong training of the emergency physicians in ECG and lysis therapy, and co-operation with nearby cardiac centres.
- [Cases and duration of mechanical ventilation in German hospitals : An analysis of DRG incentives and developments in respiratory medicine]. [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- Anaesthesist 2016 Aug 5.
Diagnosis-related groups (DRGs) have been used to reimburse hospitals services in Germany since 2003/04. Like any other reimbursement system, DRGs offer specific incentives for hospitals that may lead to unintended consequences for patients. In the German context, specific procedures and their documentation are suspected to be primarily performed to increase hospital revenues. Mechanical ventilation of patients and particularly the duration of ventilation, which is an important variable for the DRG-classification, are often discussed to be among these procedures.The aim of this study was to examine incentives created by the German DRG-based payment system with regard to mechanical ventilation and to identify factors that explain the considerable increase of mechanically ventilated patients in recent years. Moreover, the assumption that hospitals perform mechanical ventilation in order to gain economic benefits was examined.In order to gain insights on the development of the number of mechanically ventilated patients, patient-level data provided by the German Federal Statistical Office and the German Institute for the Hospital Remuneration System were analyzed. The type of performed ventilation, the total number of ventilation hours, the age distribution, mortality and the DRG distribution for mechanical ventilation were calculated, using methods of descriptive and inferential statistics. Furthermore, changes in DRG-definitions and changes in respiratory medicine were compared for the years 2005-2012.Since the introduction of the DRG-based payment system in Germany, the hours of ventilation and the number of mechanically ventilated patients have substantially increased, while mortality has decreased. During the same period there has been a switch to less invasive ventilation methods. The age distribution has shifted to higher age-groups. A ventilation duration determined by DRG definitions could not be found.Due to advances in respiratory medicine, new ventilation methods have been introduced that are less prone to complications. This development has simultaneously improved survival rates. There was no evidence supporting the assumption that the duration of mechanical ventilation is influenced by the time intervals relevant for DRG grouping. However, presumably operational routines such as staff availability within early and late shifts of the hospital have a significant impact on the termination of mechanical ventilation.
- [Pulmonary hypertension : What is new in therapy?]. [English Abstract, Journal Article]
- Anaesthesist 2016 Aug; 65(8):635-52.
Pulmonary hypertension (PH) comprises a group of pulmonary vascular diseases that are characterized by progressive exertional dyspnea and right heart insufficiency ultimately resulting in right heart decompensation. The classification is into five clinical subgroups that form the absolutely essential basis for decisions on the indications for different pharmacological and non-pharmacological forms of treatment. The guidelines were updated in 2015 and in addition to the hitherto existing pharmacological treatment options of phosphodiesterase type 5 inhibitors, endothelin receptor antagonists and prostacyclins, the soluble guanylate cyclase stimulator riociguat has now been incorporated for treatment of certain forms of PH. This article provides an overview of the new treatment recommendations in the current guidelines, e. g. for PH patients who are in intensive care units due to surgical interventions or progressive right heart insufficiency.
- [Chest pain at 32 weeks' gestation: pregnancy-related spontaneous coronary artery dissection]. [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- Anaesthesist 2016 Aug 2.
A 32-year-old woman at 32 weeks gestation presented with cardiac arrest due to ventricular tachycardia following acute chest pain at home. After immediate defibrillation with return of spontaneous circulation (ROSC), an ST segment elevation myocardial infarction due to coronary artery dissection was confirmed. Two drug-eluting stents were implanted and she was placed on dual antiplatelet therapy (DAPT). The echocardiogram showed akinesis of the apex and anterior wall. The patients risk for stent thrombosis was considered high and therefore DAPT was continued until cesarean section at 35 weeks gestation. Intraoperatively she received two units of packed red blood cells, one platelet concentrate, 4 g fibrinogen and 2 g tranexamic acid. Left ventricular ejection fraction deteriorated 8 days after delivery and the patient developed congestive heart failure.
- [The dark side of obesity]. [EDITORIAL]
- Anaesthesist 2016 Jul 22.
- [Tracheal bronchus and contralateral pneumonectomy]. [English Abstract, Journal Article]
- Anaesthesist 2016 Aug; 65(8):590-4.
One-lung ventilation is a standard procedure for many types of lung surgery. The anesthesiologist can be challenged if unknown anomalies of the bronchial tree occur. We report a patient with a tracheal bronchus on the right side presenting for left pneumonectomy, and present one possible solution to airway management.
- [Victory over surgical pain : 170 years ago the era of modern anesthesia began - but what happened in the operating theater in the time before?] [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- Anaesthesist 2016 Jul 15.
170 years ago, on 6 October 1846, the dentist William Thomas Green Morton, sucessfully demonstrated ether anesthesia in a patient undergoing surgery in the operating theater of the Massachusetts General Hospital in Boston. He thereby put an end to the unthinkable suffering of patients who had to undergo surgery when fully conscious. Before this "discovery" surgical procedures resembled a battle for life and death. Only a few documents exist illustrating the attitude of surgeons concerning their actions and which tortures patients had to tolerate. One of the first German standard operating procedures for the perioperative period was formulated in 1812 by Christian Bonifacius Zang. In her diaries and letters, the english novelist Frances Burney described her mastectomy without anesthesia on 30 September 1811. The Scottish physician and novelist John Brown, in his story of "Rab and his friends", painted a picture of the mastectomy of Ailie Noble by the famous Scottish surgeon James Syme in 1833, also without anesthesia. Finally, in his letters the Scottish scientist George Wilson described the amputation of his left foot at the ankle in January 1843, again by James Syme and again without the use of anesthesia.
- [Above and beyond BMI : Alternative methods of measuring body fat and muscle mass in critically ill patients and their clinical significance]. [JOURNAL ARTICLE, ENGLISH ABSTRACT]
- Anaesthesist 2016 Jul 13.
Obesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the "obesity paradox" is still surprising from the clinician's perspective. One explanation for the "obesity paradox" is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual's entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients' anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.