Krösbacher A, Kaiser H, Holleis S
… +3 more, Schinnerl A, Neumayr A, Baubin M
Anaesthesist
· 2021 Aug · PMID 33569715
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BACKGROUND: During the peak of the COVID-19 pandemic in spring 2020, the entire emergency rescue system was confronted with major challenges. Starting on 15 March, all tourists were asked to leave the State of Tyrol, Aus...BACKGROUND: During the peak of the COVID-19 pandemic in spring 2020, the entire emergency rescue system was confronted with major challenges. Starting on 15 March, all tourists were asked to leave the State of Tyrol, Austria. The main goal of the efforts was to ensure the usual quality of emergency medical care while reducing the physical contact during emergency interventions on site. METHODS: The Austrian Emergency Medical Service is physician-based, meaning that in addition to an ambulance team, an emergency physician (EP) is dispatched to every potential life-threatening emergency call. In Tyrol and starting on 17 March 2020, 413 types of emergency call dispatches, which were addressed with an ambulance crew as well as an EP crew before COVID-19, were now dispatched only with an ambulance crew. This procedure of dispatching differently as well as the general development of emergency calls during this period were analyzed from 15 March to 15 May 2020 and compared to the data from the same time period from 2017 to 2019. RESULTS: Despite the reduction of the population of around 30% because of absent tourists and foreign students staying in Tyrol, emergency calls with the operational keyword "difficulty in breathing/shortness of breath" rose by 18.7% (1533 vs. 1291), while calls due to traffic incidents decreased by 26.4% (2937 vs. 2161). Emergency calls with the dispatch of teams with an EP were reduced by 38.5% (1511 vs. 2456.3), whereby the NACA scores III and IV were the ones with the significant reduction of 40% each. For the reduced dispatchs, the additional dispatch of an EP team by the ambulance team amounted to 14.5%; however, for the keywords "unconscious/fainting" and "convulsions/seizures" the additional dispatch was significantly higher with over 40% each. DISCUSSION: There was an overall reduction of emergency calls. Considering, that the reduced dispatches would have led to an EP team dispatch the overall emergency doctor dispatches would have been higher than in the years before. Our study was not able to find the reasons for this increase. Only considering the additional dispatching of EPs, was this reduction in dispatching EP teams highly accurate, except for the symptoms of "unconscious/fainting" and "convulsions/seizures"; however, the actual diagnoses that the hospitals or GPs made could not be collected for this study. Therefore, it cannot be said for sure that there was equality in the quality of emergency medical care. CONCLUSION: It was possible to achieve the primary goal of reducing the physical contact with patients; however, before keeping these reductions of the dispatching order regarding. EPs for the routine operation, adaptions in these reductions as well as deeper evaluations under consideration of the data from hospitals and GPs would be necessary. Also, different options to reduce physical contact should be evaluated, e.g. building an EMT-led scout team to evaluate the patient's status while the EP team is waiting outside.
Kaltwasser A, Pelz S, Nydahl P
… +2 more, Dubb R, Borzikowsky C
Anaesthesist
· 2021 Sep · PMID 33564892
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BACKGROUND: The COVID-19 pandemic challenges hospital clinicians by additional burdens. Key questions are whether hospital clinicians have experienced more stress in the care of COVID-19 patients and whether patient safe...BACKGROUND: The COVID-19 pandemic challenges hospital clinicians by additional burdens. Key questions are whether hospital clinicians have experienced more stress in the care of COVID-19 patients and whether patient safety and quality of care have changed. METHODS: Cross-sectional study using an online survey with clinicians in German hospitals on working conditions and quality of care during the COVID-19 pandemic, comparing clinicians with (MmK) vs. without direct contact (MoK) to COVID-19 patients. RESULTS: In total, 2122 clinicians participated. Most clinicians were physicians (15.4%, n = 301) or nurses (77.0%, n = 1505) working in major acute care hospitals (46.0%, n = 899). Every second respondent stated that they worked more than usual (46.4%, n = 907) and took on additional activities (47.7%, n = 932). A quarter of the participants did not receive any training or get instructions in devices (21.5%, n = 421). Only 51.5% (n = 1006) of the respondents were provided with sufficient personal protective equipment. More than 30% (32.7%, n = 639) were more satisfied than usual. The comparing clinicans with vs. without direkt contact to Covid-19 patients worked more shifts than usual (> 2 shifts: 24.1%, n = 306 vs. 13.7%, n = 63, p < 0.001) and without instruction (27.9%, n = 364 vs. 17.1%), n = 57, p < 0.001). In terms of patient safety, there were more deficiencies in the care, mechanical ventilation and nursing (all p < 0.001). CONCLUSION: The cross-sectional study indicates an increased burden on clinicians and a restricted quality of care for patients with COVID-19. A risk to patients or clinicians cannot be excluded.
Bauer M, Groesdonk HV, Preissing F
… +3 more, Dickmann P, Vogelmann T, Gerlach H
Anaesthesist
· 2021 Aug · PMID 33559687
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BACKGROUND: The reported mortality for sepsis and septic shock varies between 15% and 59% in international comparison. For Germany, the number of studies is limited. Previous estimations of mortality in Germany are outda...BACKGROUND: The reported mortality for sepsis and septic shock varies between 15% and 59% in international comparison. For Germany, the number of studies is limited. Previous estimations of mortality in Germany are outdated or based on claims data analyses. Various authors discuss whether lacking quality initiatives and treatment standards in Germany could cause higher mortality for sepsis. This contrasts with the internationally well-recognized performance of the German intensive care infrastructure during the COVID-19 pandemic. OBJECTIVES: The objectives of this systematic review and meta-analysis were to estimate 30-day and 90-day mortality of patients with sepsis and patients with septic shock in Germany and to compare the mortality with that of other industrialized regions (Europe, North America). MATERIAL AND METHODS: A systematic literature search included interventional and observational studies published between 2009 and 2020 in PubMed and the Cochrane Library that analyzed adult patients with sepsis, severe sepsis and septic shock in Europe and North America. Studies with less than 20 patients were excluded. The 30-day and 90-day mortality for sepsis and septic shock were pooled separately for studies conducted in Germany, Europe (excluding Germany) and North America in a meta-analysis using a random effects model. Mortality over time was analyzed in a linear regression model. RESULTS: Overall, 134 studies were included. Of these, 15 studies were identified for the estimation of mortality in Germany, covering 10,434 patients, the number of patients per study ranged from 28 to 4183 patients. The 30-day mortality for sepsis was 26.50% (95% confidence interval, CI: 19.86-33.15%) in Germany, 23.85% (95% CI: 20.49-27.21%) in Europe (excluding Germany) and 19.58% (95% CI: 14.03-25.14%) in North America. The 30-day mortality for septic shock was 30.48% (95% CI: 29.30-31.67%) in Germany, 34.57% (95% CI: 33.51-35.64%) in Europe (excluding Germany) and 33.69% (95% CI: 31.51-35.86%) in North America. The 90-day mortality for septic shock was 38.78% (95% CI: 32.70-44.86%) in Germany, 41.90% (95% CI: 38.88-44.91%) in Europe (excluding Germany) and 34.41% (95% CI: 25.66-43.16%) in North America. A comparable decreasing trend in sepsis 30-day mortality was observed in all considered regions since 2009. CONCLUSION: Our analysis does not support the notion that mortality related to sepsis and septic shock in Germany is higher in international comparison. A higher mortality would not be obvious either, since intensive care, for example also during the COVID-19 pandemic, is regarded as exemplary in Germany and the structural quality, such as the number of intensive care beds per 100,000 inhabitants, is high in international comparison. Nevertheless, deficits could also exist outside intensive care medicine. A comparison of international individual studies should take greater account of the structure of healthcare systems, the severity of disease and the limitations resulting from the data sources used.
BACKGROUND: Supraglottic airway devices perform more poorly and have lower oropharyngeal leak pressure in edentulous patients than in patients with teeth. The Ambu Aura Gain is a newer second generation supraglottic airw...BACKGROUND: Supraglottic airway devices perform more poorly and have lower oropharyngeal leak pressure in edentulous patients than in patients with teeth. The Ambu Aura Gain is a newer second generation supraglottic airway device. OBJECTIVE: This randomized clinical trial assessed the oropharyngeal leak pressure in edentulous patients using the Ambu Aura Gain with a gastric tube for insertion guidance and without insertion guidance. MATERIAL AND METHODS: Patients with ASA (American Society of Anesthesiology) physical status I-III were recruited. Primary outcome was oropharyngeal leak pressure after insertion. Secondary outcome parameters were oropharyngeal leak pressure 15 min and 30 min after insertion, insertion time, insertion attempts and glottis view through flexible fiberscope. RESULTS: In this study 72 patients aged between 51 and 90 years (mean 73 years) were randomly allocated to the "with guidance" (n = 36) or the "without guidance" group (n = 36). Mean (SD) oropharyngeal leak pressure in "with guidance" and "without guidance" group was 24 cm HO and 24 cm HO (ns), respectively. A difference was found in mean insertion time with guidance versus without guidance group 52 s (45 s) vs. 26 s (15 s) (p < 0.001). No difference was found in any of the other secondary outcome parameters. CONCLUSION: A guided insertion technique does not improve oropharyngeal leak pressure of the Ambu AuraGain™ in edentulous patients. As the only difference is an increase in insertion time this technique is of no benefit for this population.
Schmoch T, Brenner T, Becker-Pennrich A
… +5 more, Hinske LC, Weigand MA, Briegel J, Möhnle P, SepNet Study Group
Anaesthesist
· 2021 Aug · PMID 33558944
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BACKGROUND: In the context of sepsis and septic shock, coagulopathy often occurs due to the close relationship between coagulation and inflammation. Sepsis-induced coagulopathy (SIC) is the most severe and potentially fa...BACKGROUND: In the context of sepsis and septic shock, coagulopathy often occurs due to the close relationship between coagulation and inflammation. Sepsis-induced coagulopathy (SIC) is the most severe and potentially fatal form. Anticoagulants used in prophylactic or therapeutic doses are discussed to potentially exert beneficial effects in patients with sepsis and/or SIC; however, due to the lack of evidence recent guidelines are limited to recommendations for drug prophylaxis of venous thromboembolism (VTE), while treatment of SIC has not been addressed. METHODS: In order to determine the status quo of VTE prophylaxis as well as treatment of SIC in German intensive care units (ICU), we conducted a Germany-wide online survey among heads of ICUs from October 2019 to May 2020. In April 2020, the survey was supplemented by an additional block of questions on VTE prophylaxis and SIC treatment in coronavirus disease 2019 (COVID-19) patients. RESULTS: A total of 67 senior doctors took part in the survey. The majority (n = 50; 74.6%) of the responses were from ICU under the direction of an anesthesiologist and/or a department of anesthesiology. Most of the participants worked either at a university hospital (n = 31; 47.8%) or an academic teaching hospital (n = 27; 40.3%). The survey results show a pronounced heterogeneity in clinical practice with respect to the prophylaxis of VTE as well as SIC treatment. In an exemplary case of pneumogenic sepsis, low molecular weight heparins (LMWH) were by far the most frequently mentioned group of medications (n = 51; 76.1% of the responding ITS). In the majority of cases (n = 43; 64.2%), anti-FXa activity is not monitored with the use of LMWH in prophylaxis doses. Unfractionated heparin (UFH) was listed as a strategy for VTE prophylaxis in 37.3% of the responses (n = 25). In an exemplary case of abdominal sepsis 54.5% of the participants (n = 36; multiple answers possible) stated the use of UFH or LMWH and UFH with dosage controlled by PTT is used on two participating ICUs. The anti-FXa activity under prophylactic anticoagulation with LMWH is monitored in 7 participating clinics (10.6%) in abdominal sepsis. Systematic screening for sepsis-associated coagulation disorders does not take place in most hospitals and patterns in the use of anticoagulants show significant variability between ICUs. In the case of COVID-19 patients, it is particularly noticeable that in three quarters of the participating ICUs the practice of drug-based VTE prophylaxis and SIC treatment does not differ from that of non-COVID-19 patients. CONCLUSION: The heterogeneity of answers collected in the survey suggests that a systematic approach to this topic via clinical trials is urgently needed to underline individualized patient care with the necessary evidence.
Oral Ahiskalioglu E, Ahiskalioglu A, Selvitopi K
… +4 more, Peksoz U, Aydin ME, Ates I, Celik M
Anaesthesist
· 2021 Dec · PMID 33507315
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BACKGROUND/OBJECTIVE: Congenital hip dysplasia (CHD) defines a spectrum of pathologies in which the acetabulum and proximal femur of babies and children abnormally develop. Open surgery in congenital hip dysplasia leads...BACKGROUND/OBJECTIVE: Congenital hip dysplasia (CHD) defines a spectrum of pathologies in which the acetabulum and proximal femur of babies and children abnormally develop. Open surgery in congenital hip dysplasia leads to severe postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided quadratus lumborum block (QLB) in pediatric patients undergoing surgery for congenital hip dysplasia. MATERIAL AND METHODS: Following ethical board approval, 40 children aged between 1-5 years undergoing surgery for congenital hip dysplasia were randomized into two groups. Patients (n = 20) received ultrasound guided quadratus lumborum block (group QLB) using 0.5 mL/kg body weight 0.25% bupivacaine preoperatively. The same standard postoperative analgesia protocol was used in both groups. Pain scores, parental satisfaction, requirement for ibuprofen and opioids were recorded. Pain was measured using the face, legs, activity, crying, consolability (FLACC) scale. RESULTS: The FLACC scores were lower at 30min and 1h, 2h, 4h, 6h, 12h and 24h in the QLB group when compared to the control group (p < 0.05). The requirement for rescue opioid analgesia was statistically significantly higher in the control group when compared to the QLB group (15/20 vs. 3/20, p < 0.001). Rate of ibuprofen usage in the ward was higher in the control group when compared to the QLB group (14/20 vs. 4/20, p = 0.004). Parental satisfaction was higher in the QLB group (p < 0.001). CONCLUSION: Ultrasound-guided quadratus lumborum block reduces pain scores and analgesic requirements following congenital hip dysplasia surgery.
Torregroza C, Roth S, Feige K
… +3 more, Lurati Buse G, Hollmann MW, Huhn R
Anaesthesist
· 2021 May · PMID 33464375
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BACKGROUND: Perioperative cardioprotection aims to minimize the consequences of myocardial ischemia reperfusion injury. These strategies appear particularly relevant for anesthesia provision during on-pump cardiac surger...BACKGROUND: Perioperative cardioprotection aims to minimize the consequences of myocardial ischemia reperfusion injury. These strategies appear particularly relevant for anesthesia provision during on-pump cardiac surgery but they potentially affect any cause of perioperative myocardial ischemia. In recent years, several pharmacological and nonpharmacological strategies of cardioprotection have been explored. Results from studies in isolated tissue and animal experiments are promising; however, translation of myocardial conditioning strategies to the clinical setting has been disappointing: in large trials cardioprotective interventions failed to significantly improve outcome. OBJECTIVE: This review aims to provide an overview of the current experimental evidence regarding pharmacological and nonpharmacological cardioprotection. Moreover, it discusses reasons why translation from bench to bedside is hampered by potential confounders and suggests future approaches that might overcome these limitations. MATERIAL AND METHODS: Narrative review. RESULTS AND CONCLUSION: Results of experimental studies are convincing but translation into clinical practice remains challenging. Several confounders have been identified contributing to the mainly inconclusive results from clinical studies, such as comorbidities and comedications, choice of anesthetic regimen and also methodological issues. Carefully designed clinical trials in well-defined patient cohorts evaluating combinations of protective strategies targeting different pathways and cell types might support bench to bedside translation.
Follmann A, Schröder H, Neff G
… +3 more, Rossaint R, Hirsch F, Felzen M
Anaesthesist
· 2021 Jan · PMID 33452557
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Telemedicine has already entered the rescue service in some regions of Germany. This case description is about a telemedical emergency physician case where an emergency doctor was also at the scene of the emergency. The...Telemedicine has already entered the rescue service in some regions of Germany. This case description is about a telemedical emergency physician case where an emergency doctor was also at the scene of the emergency. The patient had a life-threatening ventricular tachycardia and became hemodynamically unstable. The emergency physician was still inexperienced and overwhelmed by the complex situation. She decided to contact the tele-emergency medical services (tele-ems) and could then be instructed to perform intraosseous access, drug treatment and electrical cardioversion in the unstable patient. The cooperation with the tele-ems physician enabled the still inexperienced emergency physician to perform a guideline-compliant treatment and to transport the stabilized patient to the hospital in a timely manner.
Hausknecht N, Berwanger U, Conrad D
… +2 more, Kleinschmidt S, Armbruster W
Anaesthesist
· 2021 Mar · PMID 33443649
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The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous...The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.
Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether...Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.
Dittmar MS, Altmeppen J, Bigalke MU
… +2 more, Niedermirtl F, Zimmermann M
Anaesthesist
· 2021 Jul · PMID 33427914
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BACKGROUND AND OBJECTIVE: During the initial phase of the COVID-19 pandemic the government of the state of Bavaria, Germany, declared a state of emergency for its entire territory for the first time in history. Some area...BACKGROUND AND OBJECTIVE: During the initial phase of the COVID-19 pandemic the government of the state of Bavaria, Germany, declared a state of emergency for its entire territory for the first time in history. Some areas in eastern Bavaria were among the most severely affected communities in Germany, prompting authorities and hospitals to build up capacities for a surge of COVID-19 patients. In some areas, intensive care unit (ICU) capacities were heavily engaged, which occasionally made a redistribution of patients necessary. MATERIAL AND METHODS: For managing COVID-19-related hospital capacities and patient allocation, crisis management squads in Bavaria were expanded by disaster task force medical officers ("Ärztlicher Leiter Führungsgruppe Katastrophenschutz" [MO]) with substantial executive authority. The authors report their experiences as MO concerning the superordinate patient allocation management in the district of Upper Palatinate (Oberpfalz) in eastern Bavaria. RESULTS: By abandoning routine patient care and building up additional ICU resources, surge capacity for the treatment of COVID-19 patients was generated in hospitals. In parts of the Oberpfalz, ICU capacities were almost entirely occupied by patients with corona virus infections, making reallocation to other hospitals within the district and beyond necessary. The MO managed patient pathways in an escalating manner by defining local (within the region of responsibility of a single MO), regional (within the district), and cross-regional (over district borders) reallocation lanes, as needed. When regional or cross-regional reallocation lanes had to be established, an additional management level located at the district government was involved. Within the determined reallocation lanes, emitting and receiving hospitals mutually agreed on any patient transfer without explicitly involving the MO, thereby maintaining the established interhospital routine transfer procedures. The number of patients and available treatment resources at each hospital were monitored with the help of a web-based treatment capacity registry. If indicated, reallocation lanes were dynamically revised according to the present situation. To oppose further virus spreading in nursing homes, the state government prohibited patient allocation to these facilities, which led to considerably longer hospital length of stay of convalescent elderly and/or dependent patients. In parallel to the flattening of the COVID-19 incidence curve, routine hospital patient care could be re-established in a stepwise manner. CONCLUSION: Patient allocation during the state of emergency by the MO sought to keep up routine interhospital reallocation procedures as much as possible, thereby reducing management time and effort. Occasionally, difficulties were observed during patient allocations crossing district borders, if other MO followed different management principles. The nursing home blockade and conflicting financial interests of hospitals posed challenges to the work of the disaster task force medical officers.
Anaesthesist
· 2021 Feb · PMID 33410921
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Pulmonary aspiration of solid components leads to displacement of the tracheobronchial tree, the aspiration of acidic gastric juices to chemical pneumonitis (Mendelson's syndrome) and the aspiration of oropharyngeal secr...Pulmonary aspiration of solid components leads to displacement of the tracheobronchial tree, the aspiration of acidic gastric juices to chemical pneumonitis (Mendelson's syndrome) and the aspiration of oropharyngeal secretions or gastrointestinal pathogens to aspiration pneumonia. Principally, pulmonary aspiration can occur at any stage of anesthesia. In the clinical routine the aim must therefore be to identify those patients who have an increased risk of aspiration. When this is successful, measures can be taken to reduce the risk; these can be regional anaesthesia or the performance of general anaesthesia as rapid sequence induction (RSI). If severe pulmonary aspiration occurs despite all preventive measures, mostly during induction of anaesthesia, extensive experience and rapid action are necessary. This can only be achieved if the induction to RSI is performed by three persons with supervision of the trainee anaesthetist by a consultant anaesthetist.
Emons MI, Maring M, Stamer UM
… +3 more, Pogatzki-Zahn E, Petzke F, Erlenwein J
Anaesthesist
· 2021 Jun · PMID 33373025
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BACKGROUND: Patient-controlled intravenous analgesia (PCIA) is a well-established technique in acute pain management and available in most German hospitals. Despite its widespread use, information on current clinical pra...BACKGROUND: Patient-controlled intravenous analgesia (PCIA) is a well-established technique in acute pain management and available in most German hospitals. Despite its widespread use, information on current clinical practice is limited. This investigation evaluated clinical practice and monitoring as well as PCIA-associated adverse events and critical incidents in German hospitals. METHODS: An invitation to participate in this online-survey was sent to 995 heads of anesthesiology departments belonging to the "German Society of Anaesthesiology and Intensive Care Medicine". RESULTS: Of the departments receiving the link, 244 took part (response rate 25%). PCIA was used in 193 of these hospitals (79%). All the following statements relate to the hospitals in which PCIA was used. Piritramide was the most frequently used opioid. In parallel with PCIA, additional nonopioid analgesics were used in 94% of the hospitals, and in 38%, additional slow-release oral opioids were used. Parenteral opioids were administered by the ward staff in 4% of the hospitals. In 75% of hospitals, there were standardized indications for PCIA therapy, with almost two thirds of respondents stating that PCIA was the technique of second choice if regional procedures were contraindicated or failed. In all, 76% of the hospitals had an acute pain service. Twenty-four percent of the hospitals regularly used PCIA in non-surgical patients. In pediatric patients, PCIA was used in 62 hospitals (32%). Only 31% of the hospitals reported the use of standardized protocols for the specific monitoring of patients' vital signs on general wards, exceeding general care. Of the department, 158 (82%) reported adverse events in connection with the use of PCIA within the six-month period preceding the survey (most frequently due to patients' noncompliance [52%], dislocated intravenous lines [41%], communication errors [16%], administration of additional analgesics [16%] and/ or sedatives [14%], problems with the pump [16%], programming errors [9%], incorrect opioid concentration in the reservoir [8%], non-observance of contraindications [7%], incorrect dosing [6%] and self-dosing by the patient [4%] or by third parties [3%], filling the reservoir with thewrong medication [2%]; and other problems [5%]). Only 35 of the hospitals (18%) reported no problems associated with PCIA therapy. Seventy-five of the 193 respondents (39%) stated that at least one critical incident had occurred in the context of the use of PCIA. This resulted in a total of 335 cases out of an estimate of 50.000 patients treated with PCIA. The respondents classified these as follows: I) 273 incidents requiring a prolonged stay in the recovery room, but without further complications, II) 58 requiring transfer to the intensive care unit, but without further complications, III) three resulting in permanent harm to the patient and IV) one resulting in the death of the patient. A comparison of the monitoring standards for PCIA showed that critical incidents were reported less frequently in hospitals with less intensive monitoring, and more frequently in hospitals with higher monitoring standards. CONCLUSION: PCIA is a frequently used analgesic technique in German hospitals. There were many differences in how PCIA therapy was applied and monitored on general wards. Adverse events occurred to a significant extent, with a considerable part of them, which might be preventable. Critical incidents were perceived more often when standards for monitoring on general wards were higher. Consented current recommendations regarding treatment and monitoring standards as well as the systematic recording of complications when using PCIA are pending.
Schroeder I, Scharf C, Zoller M
… +8 more, Wassilowsky D, Frank S, Stecher SS, Stemmler J, Kneidinger N, Peterß S, Zwißler B, Irlbeck M
Anaesthesist
· 2021 Jul · PMID 33369696
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BACKGROUND: In a pandemic situation the overall mortality rate is of considerable interest; however, these data must always be seen in relation to the given healthcare system and the availability of local level of care....BACKGROUND: In a pandemic situation the overall mortality rate is of considerable interest; however, these data must always be seen in relation to the given healthcare system and the availability of local level of care. A recently published German data evaluation of more than 10,000 COVID-19 patients treated in 920 hospitals showed a high mortality rate of 22% in hospitalized patients and of more than 50% in patients requiring invasive ventilation. Because of the high infection rates in Bavaria, a large number of COVID-19 patients with considerable severity of disease were treated at the intensive care units of the LMU hospital. The LMU hospital is a university hospital and a specialized referral center for the treatment of patients with acute respiratory distress syndrome (ARDS). OBJECTIVE: Data of LMU intensive care unit (ICU) patients were systematically evaluated and compared with the recently published German data. METHODS: Data of all COVID-19 patients with invasive and noninvasive ventilation and with completed admission at the ICU of the LMU hospital until 31 July 2020 were collected. Data were processed using descriptive statistics. RESULTS: In total 70 critically ill patients were included in the data evaluation. The median SAPS II on admission to the ICU was 62 points. The median age was 66 years and 81% of the patients were male. More than 90% were diagnosed with ARDS and received invasive ventilation. Treatment with extracorporeal membrane oxygenation (ECMO) was necessary in 10% of the patients. The median duration of ventilation was 16 days, whereby 34.3% of patients required a tracheostomy. Of the patients 27.1% were transferred to the LMU hospital from external hospitals with reference to our ARDS/ECMO program. Patients from external hospitals had ARDS of higher severity than the total study population. In total, nine different substances were used for virus-specific treatment of COVID-19. The most frequently used substances were hydroxychloroquine and azithromycin. Immunomodulatory treatment, such as Cytosorb® (18.6%) and methylprednisolone (25.7%) were also frequently used. The overall in-hospital mortality rate of ICU patients requiring ventilation was 28.6%. The mortality rates of patients from external hospitals, patients with renal replacement therapy and patients with ECMO therapy were 47.4%, 56.7% and 85.7%, respectively. CONCLUSION: The mortality rate in the ventilated COVID-19 intensive care patients was considerably different from the general rate in Germany. The data showed that treatment in an ARDS referral center could result in a lower mortality rate. Low-dose administration of steroids may be another factor to improve patient outcome in a preselected patient population. In the authors' opinion, critically ill COVID-19 patients should be treated in an ARDS center provided that sufficient resources are available.