Search

Purpose: In Dec 2019, COVID-19 was first recognized and led to a worldwide pandemic. The German government implemented a shutdown in Mar 2020, affecting outpatient and hospital care. The aim of the present article was to evaluate the impact of the COVID-19 shutdown on patient volumes and surgical procedures of a Level I trauma center in Germany., Methods: All emergency patients were recorded retrospectively during the shutdown and compared to a calendar-matched control period (CTRL). Total emergency patient contacts including trauma mechanisms, injury patterns and operation numbers were recorded including absolute numbers, incidence proportions and risk ratios., Results: During the shutdown period, we observed a decrease of emergency patient cases (417) compared to CTRL (575), a decrease of elective cases (42 vs. 13) and of the total number of operations (397 vs. 325). Incidence proportions of emergency operations increased from 8.2 to 12.2% (shutdown) and elective surgical cases decreased (11.1 vs. 4.3%). As we observed a decrease for most trauma mechanisms and injury patterns, we found an increasing incidence proportion for severe open fractures. Household-related injuries were reported with an increasing incidence proportion from 26.8 to 47.5% (shutdown). We found an increasing tendency of trauma and injuries related to psychological disorders., Conclusion: This analysis shows a decrease of total patient numbers in an emergency department of a Level I trauma center and a decrease of the total number of operations during the shutdown period. Concurrently, we observed an increase of severe open fractures and emergency operations. Furthermore, trauma mechanism changed with less traffic, work and sports-related accidents.

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.

The complex nature and difficult-to-establish aetiology of chronic pruritus (CP) makes it challenging to provide medical care for patients with CP. This challenge can only be met with a multidisciplinary approach. The first multidisciplinary Itch Centre in Germany was established at the University of Münster in 2002 to meet the needs of this patient population. More than 2,500 outpatients and 400 inpatients are diagnosed and receive treatment each year. To ensure evidence-based medical care, an electronic system for medical documentation and patient-reported outcomes was established. Automated data transfer to a research database enables comprehensive data analysis. Our translational research has characterized peripheral and central itch mechanisms, provided novel clustering of CP patients, and identified novel target-specific therapies (e.g. neurokinin 1 receptor-antagonist). The multidisciplinary approach, combined with basic, clinical and translational research, enables comprehensive medical care of patients as well as implementation of high-quality experimental and clinical studies.

Background: Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS)., Methods: Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement., Results: Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3)., Conclusions: This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes., (© The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Aims: Cardiopulmonary resuscitation is one of the most vital therapeutic options for patients with cardiac arrest. Sufficient chest compression depth turned out to be of utmost importance to increase the likelihood of a return of spontaneous circulation. Furthermore, the use of real-time feedback-systems for resuscitation is associated with improvement of compression quality. The European Resuscitation Council changed their recommendation about minimal compression depth from 2005 (40 mm) to 2010 (50 mm). The aim of the present study was to determine whether this recommendation of the new guidelines was implemented successfully in an emergency medical service using a real-time feedback-system and to what extend a guideline-based CPR training leads to a "change in behaviour" of rescuers, respectively., Methods and Results: The electronic resuscitation data of 294 patients were analyzed retrospectively within two observational periods regarding fulfilment of the corresponding chest compression guideline requirements: ERC 2005 (40 mm) 01.07.2009-30.06.2010 (n=145) and ERC 2010 (50mm) 01.07.2011-30.06.2012 (n=149). The mean compression depth during the first period was 47.1mm (SD 11.1) versus 49.6 mm (SD 12.0) within the second period (p<0.001). With respect to the corresponding ERC Guidelines 2005 and 2010, the proportion of chest compressions reaching the minimal depth decreased (73.9% vs. 49.1%) (p<0.001). There was no correlation between compression depth and patient age, sex or duration of resuscitation., Conclusions: The present study was able to show a significant increase in chest compression depth after implementation of the new ERC guidelines. Even by using a real-time feedback system we failed to sustain chest compression quality at the new level as set by ERC Guidelines 2010. In consequence, the usefulness of a fixed chest compression depth should be content of further investigations., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: The 2010 Resuscitation Guidelines require high-quality chest compression and rapid defibrillation for patients with ventricular fibrillation with rhythm analysis and defibrillation repeated every 2 min. A lack of adherence to the guidelines by medical students was observed during simulated resuscitation training., Objectives: To assess whether real-time cardiopulmonary resuscitation guidance, including an audiovisual countdown timer, a metronome, a display of the chest compression quality and voice prompts, might improve adherence to the guidelines by medical students., Design: Randomised cross-over simulation study., Setting: Studienhospital Münster, Faculty of Medicine University Münster, Germany, Participants: One hundred and forty-one medical students (fifth year) in 47 teams., Intervention: Simulated resuscitation with and without real-time cardiopulmonary resuscitation guidance., Main Outcome Measures: The preshock pause, postshock pause, fraction of time without chest compression and defibrillation intervals. Observed quality parameters were chest compression depth and chest compression rate., Results: With real-time cardiopulmonary resuscitation guidance, there were improved mean (SD) chest compression rates (105 ± 8 vs. 121 ± 12 bpm; P < 0.005), fewer inappropriate shock intervals [median (interquartile range) 0 (1 to 5) vs. 4 (1 to 7); P < 0.005], a smaller fraction of time without chest compression (18.9 ± 4.4 vs. 22.5 ± 7.0%; P < 0.005) and shorter postshock pauses (2.3 ± 0.9 vs. 3.4 ± 1.2 s; P < 0.005)., Conclusion: Real-time cardiopulmonary resuscitation guidance significantly increased adherence to the guidelines by medical students treating simulated out-of-hospital cardiac arrest. Using a simple tool such as a countdown timer makes it possible to reduce the number of inappropriate shock intervals and time without chest compression.

Aim: Hydroxyethyl starch (HES) solutions are frequently used for perioperative volume replacement. Whereas older HES specimen tended to accumulate in the plasma and to cause negative effects on hemostasis, more recent products, e.g., HES 130/0.4, are characterised by improved pharmacological properties. The present study was designed to compare the efficacy and safety of 10% HES 130/0.4 and 10% HES 200/0.5., Methods: In this post-hoc analysis of a prospective, randomised, double-blind, multi-center therapeutic equivalence trial, 76 patients undergoing elective on-pump cardiac surgery received perioperative volume replacement using either 10% HES 130/0.4 (N.=37) or 10% HES 200/0.5 (N.=39) up to a maximum dose of 20 mL kg-1., Results: Equivalent volumes of investigational medication were infused until 24 hours after the first administration (1577 vs. 1540 mL; treatment difference 37 [-150; 223] mL; P<0.0001 for equivalence). Whereas standard laboratory tests of coagulation were comparable between groups, von Willebrand factor activity on the first postoperative morning tended to be higher following treatment with 10% HES 130/0.4 as compared to 10% HES 200/0.5 (P=0.025) with this difference being statistically significant only in the per-protocol analysis (P=0.02). Treatment groups were comparable concerning other safety parameters and the incidence of adverse drug reactions. In particular, renal function was well preserved in both groups., Conclusion: Ten percent HES 130/0.4 was equally effective and safe as compared to 10% HES 200/0.5 for volume therapy in patients undergoing cardiovascular surgery. Postoperative coagulation and renal function, as measured by standard laboratory tests, were similar among groups.

Context: The incidence of epidural haematoma after epidural anaesthesia is uncertain., Objective: To quantify epidural haematoma after epidural anaesthesia in 2008 and 2009 in a network for safety in regional anaesthesia in Germany., Design: Analysis of data systematically documented within the German network for safety in regional anaesthesia., Setting: A regional anaesthesia register for clinics recording their clinical practice was set up according to a consented protocol. After checking the registry for the presence of epidural haematoma, all participating centres were asked for the number of epidural haematoma and the number of neuraxial procedures performed during the 2 years. Patient-specific information regarding procedures and outcome were requested., Main Outcome Measures: The incidence of epidural haematoma in the network with comorbidities, coagulation status and time from first symptoms, also the performance of MRI and laminectomy., Results: During a period of 2 years, 33,142 non-obstetric epidural blocks were performed. Five thoracic epidural and one cranial haematoma occurred., Discussion: The incidence of spinal haematoma was 1: 6 628 in this general surgical population. When local anaesthetics are continuously applied, progressive motor block should increase the level of suspicion. When accompanied by pain or paraesthesia, progression to diagnosis by MRI is mandatory.

Background: Demographic development and changes in healthcare utilization have led to a rising number of calls for emergency services. In Germany life-threatening situations are responded by physician-staffed ambulances in a 2-tier system whereas paramedic-staffed ambulances are dispatched in non-life-threatening emergencies. A nationwide protocol guides dispatchers in triage decisions. In the years 1999 to 2009 a continuous rise in the number of calls for a physician-staffed ambulance in Münster was recorded. The degree of healthcare utilization according to socioeconomic status and age structure was retrospectively examined., Methods: For the year 2006 all emergency calls in the City of Münster responded to by physician-staffed ambulances were analyzed. Each call was assigned to 1 of the 45 urban districts. The local incidence of emergency calls (calls/100 residents/year) was determined and compared to the socioeconomic status which was defined as the percentage of welfare and unemployment benefit recipients per district. Patient condition was assessed by the Munich National Advisory Committee for Aeronautics (M-NACA) score. This scoring system allows calls to be allocated to either life-threatening conditions or non-life-threatening conditions by objective vital parameters. The age structure of the emergency callers was also examined., Results: Urban districts with a low socioeconomic status showed a higher incidence of emergency calls requiring physician-staffed ambulance responses than districts with a high socioeconomic status. Measured by the M-NACA scoring system, the fraction of life-threatening emergencies among all calls proved to be equal to districts with a high socioeconomic status. A correlation between elderly patients and increasing numbers of life-threatening emergencies was found., Conclusions: A low socioeconomic status of an urban district will result in more ambulance responses. However, the proportion of life-threatening emergencies is equal to districts with a high socioeconomic status. Thus, the greater need for physician-staffed ambulance responses matches clinical needs and legitimates current resource use in a 2-tier ambulance system. Indications for the abuse of physician-staffed ambulances were not found. Considering an aging population the number of emergency calls will rise in the future.

Background: Recent years have seen a rise in overall anesthesia-related mortality., Method: Selective review of the literature., Results: Anesthesia-related mortality has fallen from 6.4/10 000 in the 1940s to 0.4/100 000 at present, largely because of the introduction of safety standards and improved training. The current figure of 0.4/100 000 applies to patients without major systemic disease; mortality is higher among patients with severe accompanying illnesses, yet in this group, too, perioperative mortality can be reduced by appropriate anesthetic management. Moreover, the use of regional anesthesia can also improve the outcome of major surgery., Conclusion: A recent increase in the percentage of older and multimorbid patients among persons undergoing surgery, along with the advent of newer types of operation that would have been unthinkable in the past, has led to an apparent rise in anesthesia-associated mortality, even though the quality of anesthesiological care is no worse now than in the past. On the contrary, in recent years, better anesthetic management has evidently played an important role in improving surgical outcomes.

For years now, the German Society of Anaesthesiology and Intensive Care Medicine and the Professional Association of German Anaesthesiologists have been actively involved in efforts to improve patient safety. To this end, a whole range of activities have been initiated in recent years and, since February 2011, collected together on our home page 'PATSI' (www.patientensicherheit-ains.de). Further, the implementation of syringe labelling (ISO 26825) with additional information on drugs frequently used in intensive care was carried out. Under the item Helsinki Declaration, all decisions and recommendations so far worked out by our speciality have, in structured form, been assigned to individual points and saved as PDF files. This has made it possible for every anaesthesiological department in Germany to integrate all the relevant instructions and conditions of the Helsinki Declaration into their own individual work structures. These systematic solutions represent a major contribution towards reducing the possibility of errors at the workplace. We are certainly still in the early stages of our efforts to achieve a nationwide integration of a cultural change in the way we deal with mistakes in medicine. We have incorporated the item 'learning from mistakes' in our project 'critical incident reporting system for anaesthesia, intensive care medicine, emergency care, and pain therapy, CIRS-AINS', and have brought out a range of relevant illustrative publications. Accepting these 'mistakes' as an opportunity to critically examine ourselves and our work with a view to learning from them and further improving our speciality service is, we believe, a great challenge for future developments in anaesthesia., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background and Objectives: In Germany there is considerable variability in the organizational forms of intensive-care medicine. We present economical data that arose during the reorganization of an intensive care unit with the implementation of the continuous presence of a trained intensivist. The unit was changed from an intensive-observational unit managed by four surgical departments without continuous presence of a trained intensivist to an interdisciplinary surgical intensive care unit managed by the Department of Anaesthesia in co-operation with the surgical departments with the continuous presence of trained intensivists., Methods: Measurement of costs for personnel, medical equipment and external services, revenues, length of hospital stay and complications of cardiac surgical patients., Results: Per year costs for personnel increased by approximately euro240,000, while expenses for medical equipment were reduced by euro245,000. In all, 466 hospital days were saved by the reduction in the length of hospital stay, providing capacity for 22 additional cardiac surgical cases. In addition, the presence of trained intensivists made it possible to provide care for more severely ill patients, which gained approximately 100 additional case-mix points and increased the hospital's revenues by more than euro300,000. Emergency readmission to the intensive care unit was reduced by 17%. The number of patients requiring renal replacement therapy and those developing non-occlusive mesenteric ischaemia was substantially reduced., Conclusion: In addition to the medical advantages, staffing the intensive care unit with trained intensivists 24 h a day was of appreciable economical benefit.

Neuroaxial anesthesia has become an integral part of perioperative pain therapy and provides several advantages over systemic opioids. Despite these benefits, rare but serious complications occur with epidural analgesia including epidural haematoma, spinal-epidural infections and local anesthetic cardiac toxicity. Epidural haematoma and epidural abscess after catheter placement may cause irreversible neurological complications and an immediate diagnostic and therapeutic approach is crucial to assure complete recovery. Furthermore, local anesthetic-induced cardiac toxicity is another rare but potentially lethal complication during regional anesthesia. Based on lipophilic and hydrophilic properties, local anesthetics can interfere with ion channels such as sodium, potassium and calcium channels of the CNS and the heart leading to severe neuronal and cardiac (arrhythmia and contractile depression) adverse effects. In this review we take an in-depth look at severe complications associated with regional anesthesia, describe their symptoms and discuss appropriate diagnostic and therapeutical approaches.

Pain is the most frequent and straining symptom after surgery. Regardless of the severity of the surgical trauma patients may suffer from severe pain and may therefore not tolerate or even refuse important postoperative interventions for fear of pain. This may influence the outcome and worsen the prognosis of surgical patients. Physicians are therefore ethically and legally bound to care for adequate pain management. Regional anesthesia, especially epidural analgesia, is most effective to treat postoperative pain. It is discussed whether the incidence and severity of chronic postoperative pain can be reduced and postoperative complications can be prevented by this technique. Epidural analgesia may reduce the risk of postoperative complications (i.e. myocardial infarction) by reducing the surgical stress response and inhibiting the pathophysiological cascade that may trigger undesirable sequelea.

Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. Facing restricted capacities in intensive therapy (ITU) and high dependency units (HDU) the PACU serves as a buffer; intensive care functions can be covered here until the patient can be admitted to an intensive care unit. In this context, the PACU also has a switch function; postoperatively, the patient is evaluated here and the level for further treatment determined: ITU, HDU, or normal ward. The PACU period can be utilised to improve the patient's condition (upgrade function) enabling continuation of treatment on a lower level (HDU instead of ITU, normal ward instead of HDU). This combination of buffer, switch and upgrade function is of special importance when ITU and HDU resources are limited. A new task for the PACU arises from efforts to optimise acute pain therapy; initial adjustment of continuous infusion systems according to the patients' needs can be performed here without additional staffing requirements. Finally, the PACU can be used preoperatively for "tune up" procedures in high risk patients. The basis for co-operation between anaesthetist and surgeon is the separation of responsibilities in combination with mutual trust. Accordingly, the anaesthetist is responsible for monitoring and maintenance of vital functions. Consequently, the anesthetist has a professional and organisational responsibility in the PACU. The surgeon can and must rely on notification whenever surgical complications may require his intervention. With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU.

Many articles in the literature document the fact that postoperative pain therapy has not improved for decades despite new insights into pain physiology, the availability of powerful analgesics and the development of new techniques. This project was set up to develop practical, effective, safe, and easy to run acute pain therapy. METHODS. Postoperative pain management had to be optimized according to the facilities available today. Therefore, the legal background is presented first. Second, several medical and organizational principles were chosen to serve as a basis for the new organizational structure: Continuously monitoring the patient's pain during the whole stay in hospital, Introduction of a simple verbal 4-point pain score for determination and documentation of pain allowing the nurses to differentiate pain that should be treated or not, A simple sedation score, Use of "balanced analgesia" and "pre-emptive analgesia", Drug administration according to the needs of the patient, Partial transfer of the responsibility for pain treatment to nurses. Plans and algorithms were expanded to allow nurses and anaesthesiologists to reach the previously determined goals. RESULTS. In a small study including 107 patients, it was demonstrated that the quality of pain treatment improved significantly. Furthermore, patients, nurses and physicians are much more content with the new pain treatment regimen. DISCUSSION. The difficulties in realizing such a concept are described. The importance of thorough teaching is underlined in a nurse-based system. However, it is not yet clear whether this pain treatment has resulted in reduced morbidity, reduced mortality and a shortened hospital stay of the patients.