BACKGROUND: In Germany, postmortem organ donation requires a diagnosis of irreversible brain death (BD) in strict compliance with the guidelines of the German Medical Association. OBJECTIVE: Identification of factors tha...BACKGROUND: In Germany, postmortem organ donation requires a diagnosis of irreversible brain death (BD) in strict compliance with the guidelines of the German Medical Association. OBJECTIVE: Identification of factors that have a limiting effect on the initiation and execution of BD diagnostics. Identification of potential for improvement. MATERIAL AND METHODS: Anonymous survey of transplantation officials in hospitals in Berlin, Brandenburg and Mecklenburg-Western Pomerania. RESULTS: There is considerable heterogeneity with respect to the frequency of BD diagnostics and hospital-specific procedures, including the use of an existing consultation service. The local availability of qualified doctors and of suitable ancillary diagnostic tests has a structurally limiting effect. This is especially true for pediatric patients. Potential for improvement was seen in the identification of affected patients, the motivation of staff and the role of transplantation officials. CONCLUSION: According to the recently amended German Transplantation Act, a centrally organized consultation service for BD diagnostics must be implemented as soon as 2021. Recommendations can be derived from the present survey and from the experience of the regionally established consultation service. In addition to neurological and neurosurgical expertise, qualified pediatricians and mobile ancillary instrumental diagnostics should also be provided. Expert advice from neurointensive care physicians should be available at an early stage in order to identify potentially affected patients. The highly variable participation of hospitals in organ donation, despite the availability of an expert diagnostic service free of charge, points to an important role of additional factors, some of which may be nonmedical in nature.
Weissenbacher A, Bolz R, Zimmermann A
… +3 more, Donaubauer B, Stehr SN, Hempel G
Anaesthesist
· 2021 Jun · PMID 33315142
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BACKGROUND: The final year of medical training in Germany is one of the least structured and standardized years of medical school. Medical students often complain about a lack of guidance, supervision and feedback. They...BACKGROUND: The final year of medical training in Germany is one of the least structured and standardized years of medical school. Medical students often complain about a lack of guidance, supervision and feedback. They are mostly asked to perform delegable nonmedical tasks even though student experiences in this period critically determine future decisions for certain medical specialties. Consequently, right from the beginning many young professionals feel overburdened especially by the time pressure of everyday clinical practice. The planned amendment of the medical licensing regulations will make competence-based training even more important. This article therefore aims to examine the extent to which a mentoring-based curriculum with workplace-based examinations during the final year of medical studies can make a valuable contribution to this. METHODS: After a needs assessment (structured literature search, results evaluation and focus groups with both students and medical specialists), a mentoring-based curriculum for final year medical students was developed following the Kern cycle. In 2 work sessions 10 discipline-specific competencies for the fields of anesthesiology, critical care, emergency and pain medicine were established and prioritized, which had to be mastered by every student independently at the end of the training period. Assessment of these competencies was performed on a regular basis by trained mentors in the form of workplace-based assessments (mini-clinical evaluation exercise, mini-CEX, direct observation of procedural skills, DOPS). Multiperspective evaluation was and is the foundation of continuous program development. By September 2019 a total of 40 students had completed the modified curriculum and were subsequently interviewed online about various aspects of the tertial. RESULTS: The response rate to the survey was 80% (n = 32). The gender ratio was balanced (male = 50%, female = 50%). Prioritization and assessment of 10 competencies by trained mentors enabled a focused, demand-driven and high-quality training of final year medical students. Surveyed students found the section mentoring and feedback to be very positive and it supported their learning success (grade 1.5). Despite firmly established feedback structures, in retrospect almost half (51.6%) wanted more structured feedback. Workplace-based assessments were mostly previously unknown (64.6%) but were experienced as helpful and meaningful (76.7%). Students felt confident and prepared for the final state examination (81.3%) and their career start (71.0%) after being part of the program. These findings were accompanied by a high level of satisfaction (grade 1.7) as well as a high recommendation rate for this institution (as a training program for final year medical students and as a career start for residents, both with 93.7%). Thus, the good evaluation results of the department before the start of the project could again be slightly improved. CONCLUSION: A demand-driven, mentoring-based curriculum with integrated workplace-based assessments not only led to high overall student satisfaction but also promoted the quality of teaching in an effective and resource-saving way. Mentoring promotes learning success mainly through feedback and individual learning support and also supports the communicative and social skills of students and mentors alike.
Siegler BH, Gruß M, Oehler B
… +5 more, Keßler J, Fluhr H, Weis C, Schulz F, Weigand MA
Anaesthesist
· 2021 May · PMID 33301057
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BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 11% of patients after spinal anesthesia and in more than 80% after dural perforation upon epidural anesthesia. It represents a severe anesthesiological compl...BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 11% of patients after spinal anesthesia and in more than 80% after dural perforation upon epidural anesthesia. It represents a severe anesthesiological complication in obstetric patients. If conservative medication measures do not result in a timely relief of symptoms, the current guidelines recommend the early implementation of an epidural blood patch; however, although performing an epidural blood patch is effective to treat PDPH, potential side effects include neurological complications, spinal hematoma and infections. Assumed to reduce cerebral vasodilatation as a potential pathophysiological driver of PDPH, the transnasal block of the sphenopalatine ganglion with local anesthetics is discussed as an alternative approach. METHODS: In this case study a modification of this technique is reported using a mucosal atomization device (MAD) for off-label nasal administration of lidocaine in two obstetric patients suffering from PDPH. Up to now there is no experience with this modified technique in obstetric anesthesiology. RESULTS: The first patient (25-year-old secundigravida, body mass index [BMI] 54.7 kg/m) displayed a pronounced PDPH with nausea and vomiting during the first day after a cesarean section under spinal anesthesia (3 attempts). The second patient (32-year-old tertiagravida, BMI 27.3 kg/m) was readmitted to hospital due to PDPH 4 days after a natural birth under epidural anesthesia. Whereas conservative measures and therapeutic attempts with nonopioid analgesics and caffeine did not result in a sufficient treatment success, intranasal lidocaine administration via a MAD led to an immediate and persisting symptom relief. Both patients could be discharged from hospital after 24 h of surveillance and did not report any relevant side effects of the lidocaine administration. CONCLUSION: The described noninvasive and simple procedure represents a valuable addition to previously known treatment options for PDPH and a potential alternative to an epidural blood patch in obstetric patients with PDPH. Prospective studies are needed to validate the findings.
Anaesthesist
· 2021 Apr · PMID 33294947
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Segawa syndrome (dopa-responsive dystonia [DRD]) is a rare neurometabolic disorder characterized by progressive dystonia, diurnal variation and tremors. It is caused by an enzymatic defect (a mutation of the GTPCH1 gene...Segawa syndrome (dopa-responsive dystonia [DRD]) is a rare neurometabolic disorder characterized by progressive dystonia, diurnal variation and tremors. It is caused by an enzymatic defect (a mutation of the GTPCH1 gene located on chromosome 14q) in the synthesis of tetrahydrobiopterin, an important substrate for dopamine synthesis. In the case of early correct diagnosis, clinical symptoms are well-controlled by levodopa therapy. The disease has several features which may lead to organ dysfunctions (e.g. torticollis, scoliosis, dysphagia and immobilization), which may be of concern for the anesthesiologist. Presenting two case reports of female patients undergoing elective cesarean section and breast cancer surgery, the main principles of perioperative management are discussed. Either techniques of regional or general anesthesia can be performed safely. Preoperative medication with levodopa should not be interrupted. Pharmacological agents with an antidopaminergic mode of action have to be avoided as well as significant pain and emotional stress situations in the perioperative period. Surgery in an ambulatory setting may not be recommended.
Anaesthesist
· 2021 Jan · PMID 33258991
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The immune system is an effective defense against invading pathogens and is accompanied by recruitment of immune cells and initiation of an inflammatory reaction. This can also be triggered by noninfectious stimuli, e.g....The immune system is an effective defense against invading pathogens and is accompanied by recruitment of immune cells and initiation of an inflammatory reaction. This can also be triggered by noninfectious stimuli, e.g. a large surgical intervention and cause severe tissue destruction and organ dysfunction. The organism cannot distinguish many stimuli that are released during a large surgical intervention from exogenous pathogens. Therefore, there is a high risk for the occurrence of systemic inflammatory reactions, particularly in large surgical interventions. This excessive immune response leads to release of proinflammatory cytokines, endothelial dysfunction, damage to the glycocalyx, activation of leukocytes as well as tissue and organ destruction. This article summarizes the molecular principles of the surgery-associated inflammatory reaction, the differentiation from other inflammatory complications and treatment options.
Anaesthesist
· 2021 May · PMID 33258990
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BACKGROUND: Survival rates after an out-of-hospital cardiac arrest (OHCA) remain low. Extracorporeal cardiopulmonary resuscitation (eCPR) has been introduced as an attempt to increase survival in selected patients and ob...BACKGROUND: Survival rates after an out-of-hospital cardiac arrest (OHCA) remain low. Extracorporeal cardiopulmonary resuscitation (eCPR) has been introduced as an attempt to increase survival in selected patients and observational studies have shown promising results. Nevertheless, inclusion criteria and timing of eCPR remain undefined. OBJECTIVE: The current study analyzed a load and go strategy with respect to the golden hour of eCPR as a cut-off time for survival and favorable neurological outcome. MATERIAL AND METHODS: This retrospective cohort study included 32 patients who underwent eCPR treatment due to an OHCA between January 2017 and September 2019. Routinely taken patient demographic data (age, BMI, sex) were analyzed. The main focus was set on processing times in the preclinical and clinical setting. Time intervals including OHCA until ambulance arrival, time on scene, transportation times and door to eCPR were extracted from emergency medical service (EMS) and resuscitation protocols. Low-flow times, survival and neurological outcome were analyzed. RESULTS: The use of eCPR in OHCA was associated with survival to hospital discharge in 28% and a good neurological outcome in 19% of the cases. Both groups (survivor and nonsurvivor) did not differ in patient demographics except for age. Survivors were significantly younger (47 (30-60) vs. 59 (50-68) years, p = 0.035). Processing times as well as low-flow times were not significantly different (OHCA-eCPR survivor 64 (50-87) vs. non-survivor 74 (51-85) min; p-value 0.64); however, median low-flow times were outside the golden hour of eCPR (69 (52-86)). CONCLUSION: Despite low-flow times of more than 60 min, eCPR was associated with survival in 28% after OHCA. Hence, exceeding the golden hour of eCPR cannot act as a definitive exclusion criterion for eCPR.
Kluge S, Janssens U, Welte T
… +12 more, Weber-Carstens S, Schälte G, Salzberger B, Gastmeier P, Langer F, Welper M, Westhoff M, Pfeifer M, Hoffmann F, Böttiger BW, Marx G, Karagiannidis C
Anaesthesist
· 2021 Dec · PMID 33245382
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Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for cli...Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.
Dahmen J, Bäker L, Breuer F
… +4 more, Homrighausen K, Pommerenke C, Stiepak JK, Poloczek S
Anaesthesist
· 2021 May · PMID 33245381
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BACKGROUND: The COVID-19 pandemic represents an unprecedented severe test for emergency medicine in Germany. In addition to in-hospital emergency medicine, prehospital emergency medicine has the decisive task of fully gu...BACKGROUND: The COVID-19 pandemic represents an unprecedented severe test for emergency medicine in Germany. In addition to in-hospital emergency medicine, prehospital emergency medicine has the decisive task of fully guaranteeing emergency medical healthcare. In this article the Berlin Fire Brigade shows new ways for emergency medical services to fulfil these increased responsibilities during the pandemic in prehospital emergency medicine in the State of Berlin. METHODS: A systematic presentation of the challenges and conceptional responses of preclinical emergency medicine to the COVID-19 pandemic was carried out using the example of the emergency medical services in the State of Berlin. RESULTS: The Berlin Fire Brigade has a dispatch center that coordinates all requests for assistance in the State of Berlin over the emergency telephone number 112. On average a total of 2565 emergency calls are received every 24 h, from which 1271 missions are generated. During the pandemic there was a striking increase in missions to patients with acute respiratory diseases (ARD). Of the missions 11% were carried out to patients with the suspicion of COVID-19. The duration of the emergency calls was extended on average by 1:36 min due to the additional questions in the pandemic protocol and the duration of the mission by an average of 17 min with the additional alarm keyword acute respiratory disease (ARD). CONCLUSION: The continuing pandemic reveals that tasks and responsibilities of public services in emergency rescue go far beyond the immediate medical prevention of danger to life and limb. In addition to the controller and triage functions in the integrated dispatch center of the Berlin Fire Brigade (112), the emergency and healthcare measures could be ensured. This was accomplished by comprehensive measures for situation control, situation reports and mastering situations despite the lack of alternative outpatient care options, especially in the areas of general practitioner, public health care and medical specialist practices.
Felzen M, Schröder H, Beckers SK
… +14 more, Böttiger BW, Rott N, Koch-Schultze R, Wingen S, Meißner A, Santowski I, Picker O, Rahe-Meyer N, Dumcke R, Wegner C, van Aken H, Gottschalk A, Weber O, Rossaint R
Anaesthesist
· 2021 May · PMID 33244640
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BACKGROUND: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the...BACKGROUND: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017. OBJECTIVE: The aim of this work was to evaluate this project. MATERIAL AND METHODS: All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students. RESULTS: In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year. CONCLUSION: A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.
Schulz J, Scholler A, Frank P
… +4 more, Scheinichen D, Flentje M, Eismann H, Palmaers T
Anaesthesist
· 2021 Apr · PMID 33231715
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BACKGROUND: The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standar...BACKGROUND: The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists. OBJECTIVE: The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures. MATERIAL AND METHODS: Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated. RESULTS: The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture. CONCLUSION: In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.
Schemke S, Schwalbe H, Grunewald L
… +1 more, Maurer H
Anaesthesist
· 2021 Apr · PMID 33231714
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BACKGROUND: The logistic peculiarities of an emergency maritime location and the frequent additional threat of accidental hypothermia mean that the treatment of medical emergencies at sea are particularly demanding. This...BACKGROUND: The logistic peculiarities of an emergency maritime location and the frequent additional threat of accidental hypothermia mean that the treatment of medical emergencies at sea are particularly demanding. This article describes the characteristics of emergency medical missions of the German Maritime Search and Rescue Service (DGzRS) as the main provider of non-helicopter-based medical maritime rescue on the seas off the coasts of Germany. MATERIAL AND METHODS: A retrospective analysis of all missions by the DGzRS in 2017 and 2018 was carried out. The data and times of the missions as well as the severity of the diseases of the patients (graduated using the NACA score) were evaluated and exemplarily compared to those of a medical emergency ambulance service from the City of Lübeck. RESULTS: In a total of 182 medical missions 224 patients were treated. The mission units of the DGzRS needed a mean time of 30 ± 21 min up to arrival and 43 ± 30 min for rescue, treatment and transport. In 63 missions the patients were accompanied by an emergency physician, who was brought in from the ground rescue service in 44 missions. Due to the waiting time for boarding of the additional personnel, the departure in 26 missions was delayed by an average of 18 ± 7 min. The average severity of the disease in the maritime rescue was significantly higher than in the emergency medical service of Lübeck but the number of resuscitations and fatalities were comparable. CONCLUSION: Although the severity of medical emergencies on the seas off the coasts of Germany was high, the emergency physicians frequently arrived with a considerable delay. There is an urgent need for an effective support of the DGzRS by medical personnel specifically trained for maritime missions.
Anaesthesist
· 2020 Dec · PMID 33210184
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Regional anesthesia of the upper extremities is now part of the standard repertoire of a clinical anesthesiologist. Assigning the correct procedure to the individual needs of the patient is becoming increasingly more dif...Regional anesthesia of the upper extremities is now part of the standard repertoire of a clinical anesthesiologist. Assigning the correct procedure to the individual needs of the patient is becoming increasingly more difficult due to the wide variety of options. The principle use of regional anesthesiological procedures is hardly ever questioned anymore but it needs to be carefully considered and must be adapted exactly to the case at hand.
Michels P, Meyer EC, Brandes IF
… +1 more, Bräuer A
Anaesthesist
· 2021 May · PMID 33196882
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The entry of gases into the vascular system is called vascular air embolism (VAE). The blocking of the pulmonary circulation by VAE can lead to fulminant right-sided heart failure and cardiocirculatory arrest. A VAE can...The entry of gases into the vascular system is called vascular air embolism (VAE). The blocking of the pulmonary circulation by VAE can lead to fulminant right-sided heart failure and cardiocirculatory arrest. A VAE can occur at any time if there is an open connection between the environment and a venous vessel with subatmospheric pressure. This situation occurs during ear nose throat surgery, hip surgery, surgery of the lesser pelvis or breast surgery, if the surgical field is above the level of the heart; however, a VAE can also occur during routine tasks, such as insertion or removal of a central venous catheter or during endoscopic procedures with the insufflation of gas.Because during these procedures VAE is not the main focus of the anesthesia or surgery personnel, in such situations its sudden unexpected occurrence can have severe consequences. In contrast, in cardiac surgery or neurosurgery the risk of intraoperative VAE is much better known. In procedures with a higher risk of a clinically relevant VAE, a patent foramen ovale should be ruled out by preoperative transesophageal echocardiography (TEE). Intraoperatively TEE is the most sensitive procedure not only to detect a VAE but also to visualize the clinical expression, e.g. acute right heart overload.The avoidance of an initial and repeated air embolism is the primary measure to minimize the incidence and severity of VAE.Intraoperatively the following measures should be undertaken: excellent communication between anesthesia and surgery personnel with predetermined actions, maintenance of normal volume, patient positioning with minimal difference in height between heart and head, state of the art surgical technique with closure of potential air entry sites, sufficient detection of air by TEE, repeated jugular vein compression during neurosurgery, intraoperative Trendelenburg positioning of the patient during persisting or clinically evident VAE, differentiated adjustment of ventilatory settings and catecholamine treatment, aspiration of the blood-air mixture (air lock) at the junction of the superior vena cava and right atrium through a large bore central venous line and keeping check of the coagulation status.