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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. Simulation of the mortality after different ex ante (secondary) and ex post (tertiary) triage methods in people with disabilities and pre-existing diseases. Anaesthesiologie 2023; 72:10-18. [PMID: 37733034 PMCID: PMC10692011 DOI: 10.1007/s00101-023-01336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
| | - Jens O Brunner
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Denmark
| | - Axel R Heller
- Clinic for Anaesthesiology and Operative Intensive Care, Medical Faculty, University Hospital of Augsburg, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Georg Marckmann
- Institute for Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, Munich, Germany
| | - Christina C Bartenschlager
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Applied Data Science in Healthcare, Nürnberg School of Health, Klinikum Nürnberg and Ohm University of Applied Sciences Nuremberg, Keßlerplatz 12, Nuremberg, Germany
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Heller AR, Neidel T, Klotz PJ, Solarek A, Kowalzik B, Juncken K, Kleber C. Validation of secondary triage algorithms for mass casualty incidents : A simulation-based study-English version. Anaesthesiologie 2023; 72:1-9. [PMID: 37823925 PMCID: PMC10692258 DOI: 10.1007/s00101-023-01292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.
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Affiliation(s)
- Axel R Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Tobias Neidel
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
- Interdisciplinary Emergency Department, Medical Faculty, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Patrick J Klotz
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - André Solarek
- Department of Disaster preparedness and Emergency Planning, Charité, Berlin, Germany
| | - Barbara Kowalzik
- Division III.3 Protection of Health, German Federal Office for Civil Protection and Disaster Assistance, Bonn, Germany
| | - Kathleen Juncken
- Medical Directorate, Dresden Municipal Hospital, Dresden, Germany
| | - Christan Kleber
- Clinic and Polyclinic for Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig AöR, Leipzig, Germany
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Bartenschlager CC, Grieger M, Erber J, Neidel T, Borgmann S, Vehreschild JJ, Steinbrecher M, Rieg S, Stecher M, Dhillon C, Ruethrich MM, Jakob CEM, Hower M, Heller AR, Vehreschild M, Wyen C, Messmann H, Piepel C, Brunner JO, Hanses F, Römmele C. Covid-19 triage in the emergency department 2.0: how analytics and AI transform a human-made algorithm for the prediction of clinical pathways. Health Care Manag Sci 2023; 26:412-429. [PMID: 37428304 PMCID: PMC10485125 DOI: 10.1007/s10729-023-09647-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 06/01/2023] [Indexed: 07/11/2023]
Abstract
The Covid-19 pandemic has pushed many hospitals to their capacity limits. Therefore, a triage of patients has been discussed controversially primarily through an ethical perspective. The term triage contains many aspects such as urgency of treatment, severity of the disease and pre-existing conditions, access to critical care, or the classification of patients regarding subsequent clinical pathways starting from the emergency department. The determination of the pathways is important not only for patient care, but also for capacity planning in hospitals. We examine the performance of a human-made triage algorithm for clinical pathways which is considered a guideline for emergency departments in Germany based on a large multicenter dataset with over 4,000 European Covid-19 patients from the LEOSS registry. We find an accuracy of 28 percent and approximately 15 percent sensitivity for the ward class. The results serve as a benchmark for our extensions including an additional category of palliative care as a new label, analytics, AI, XAI, and interactive techniques. We find significant potential of analytics and AI in Covid-19 triage regarding accuracy, sensitivity, and other performance metrics whilst our interactive human-AI algorithm shows superior performance with approximately 73 percent accuracy and up to 76 percent sensitivity. The results are independent of the data preparation process regarding the imputation of missing values or grouping of comorbidities. In addition, we find that the consideration of an additional label palliative care does not improve the results.
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Affiliation(s)
- Christina C Bartenschlager
- Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159, Augsburg, Germany
- Professor of Applied Data Science in Health Care, Nürnberg School of Health, Ohm University of Applied Sciences Nuremberg, Nuremberg, Germany
- Anaesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Milena Grieger
- Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159, Augsburg, Germany
| | - Johanna Erber
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, University Hospital Rechts Der Isar, Munich, Germany
| | - Tobias Neidel
- Anaesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Stefan Borgmann
- Hygiene and Infectiology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Jörg J Vehreschild
- Department of Internal Medicine, Hematology and Oncology, Goethe University Frankfurt, Frankfurt Am Main, Germany
- Department I of Internal Medicine, University of Cologne, University Hospital of Cologne, Cologne, Germany
- German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Markus Steinbrecher
- Clinic for Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Siegbert Rieg
- Clinic for Internal Medicine II - Infectiology, University Hospital Freiburg, Freiburg, Germany
| | - Melanie Stecher
- Department I of Internal Medicine, University of Cologne, University Hospital of Cologne, Cologne, Germany
- German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Christine Dhillon
- COVID-19 Task Force, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Maria M Ruethrich
- Hematology and Internal Oncology, University Hospital Jena, Jena, Germany
| | - Carolin E M Jakob
- Department I of Internal Medicine, University of Cologne, University Hospital of Cologne, Cologne, Germany
- German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Martin Hower
- Pneumology, Infectiology and Internal Intensive Care Medicine, Klinikum Dortmund, Germany
| | - Axel R Heller
- Anaesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Maria Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Christoph Wyen
- Praxis am Ebertplatz, Cologne, Germany
- Department of Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Helmut Messmann
- Clinic for Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Christiane Piepel
- Department of Hemato-Oncology and Infectious Diseases, Klinikum Bremen-Mitte, Bremen, Germany
| | - Jens O Brunner
- Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159, Augsburg, Germany.
- Department of Technology, Management, and Economics, Technical University of Denmark, Hovedstaden, Denmark.
- Data and Development Support, Region Zealand, Denmark.
| | - Frank Hanses
- Internal Medicine and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Römmele
- Clinic for Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
- COVID-19 Task Force, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. [Simulation of mortality after different ex-ante and ex-post-triage methods in people with disabilities and comorbidities]. Anaesthesiologie 2023:10.1007/s00101-023-01302-3. [PMID: 37358616 PMCID: PMC10400691 DOI: 10.1007/s00101-023-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/10/2023] [Indexed: 06/27/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
| | - Jens O Brunner
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Dänemark
| | - Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universitätsklinikum Augsburg, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Georg Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, München, Deutschland
| | - Christina C Bartenschlager
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professur für Angewandte Datenwissenschaften im Gesundheitswesen, Nürnberg School of Health, Technische Hochschule Nürnberg Georg Simon Ohm, Klinikum Nürnberg, Nürnberg, Deutschland
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Heller AR, Neidel T, Klotz PJ, Solarek A, Kowalzik B, Juncken K, Kleber C. [Validation of secondary triage algorithms for mass casualty incidents-A simulation-based study-German version]. Anaesthesiologie 2023:10.1007/s00101-023-01291-3. [PMID: 37318526 DOI: 10.1007/s00101-023-01291-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.
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Affiliation(s)
- Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Tobias Neidel
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
- Interdisziplinäre Notaufnahme, Medizinische Fakultät, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - Patrick J Klotz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - André Solarek
- Stabsstelle Katastrophenschutz, Charité, Berlin, Deutschland
| | - Barbara Kowalzik
- Referat III.3 Schutz der Gesundheit, Bundesamt für Bevölkerungsschutz und Katastrophenhilfe, Bonn, Deutschland
| | - Kathleen Juncken
- Medizinisches Direktorium, Städtisches Klinikum Dresden, Dresden, Deutschland
| | - Christan Kleber
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie (OUP), Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
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Heller AR, Bartenschlager C, Brunner JO, Marckmann G. [German "Triage Act"-Regulation with fatal consequences]. Anaesthesiologie 2023:10.1007/s00101-023-01286-0. [PMID: 37233790 DOI: 10.1007/s00101-023-01286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/27/2023]
Abstract
With the coming into force of § 5c of the Infection Protection Act (IfSG), the so-called Triage Act, on 14 December 2022, a protracted discussion has come to a provisional conclusion, the result of which physicians and social associations but also lawyers and ethicists are equally dissatisfied. The explicit exclusion of the discontinuation of treatment that has already begun in favor of new patients with better chances of success (so-called tertiary or ex-post triage) prevents allocation decisions with the aim of enabling as many patients as possible to beneficially participate in medical care under crisis conditions. The result of the new regulation is de facto a first come first served allocation, which is associated with the highest mortality even among individuals with limitations or disabilities and was rejected by a large margin as unfair in a population survey. Mandating allocation decisions based on the likelihood of success but which are not permitted to be consistently implemented and prohibiting, for example the use of age and frailty as prioritization criteria, although both factors most strongly determine the short-term probability of survival according to evident data, shows the contradictory and dogmatic nature of the regulation. The only remaining possibility is the consistent termination of treatment that is no longer indicated or desired by the patient, regardless of the current resource situation; however, if a different decision is made in a crisis situation than in a situation without a lack of resources, this practice would not be justified and would be punishable. Accordingly, the highest efforts must be set on legally compliant documentation, especially in the stage of decompensated crisis care in a region. The goal of enabling as many patients as possible to beneficially participate in medical care under crisis conditions is in any case thwarted by the new German Triage Act.
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Affiliation(s)
- A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - C Bartenschlager
- Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland
| | - J O Brunner
- Zentrum für Interdisziplinäre Gesundheitsforschung, Universität Augsburg, Augsburg, Deutschland
| | - G Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
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Pradelli L, Mayer K, Klek S, Rosenthal MD, Povero M, Heller AR, Muscaritoli M. Omega-3 fatty acids in parenteral nutrition - A systematic review with network meta-analysis on clinical outcomes. Clin Nutr 2023; 42:590-599. [PMID: 36878111 DOI: 10.1016/j.clnu.2023.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND & AIMS Accumulating scientific evidence supports the benefits of parenteral nutrition (PN) with fish oil (FO) containing intravenous lipid emulsions (ILEs) on clinical outcomes. Yet, the question of the most effective ILE remains controversial. We conducted a network meta-analysis (NMA) to compare and rank different types of ILEs in terms of their effects on infections, sepsis, ICU and hospital length of stay, and in-hospital mortality in adult patients. METHODS MEDLINE, EMBASE, and Web of Science databases were searched for randomized controlled trials (RCTs) published up to May 2022, investigating ILEs as a part of part of PN covering at least 70% of total energy provision. Lipid emulsions were classified in four categories: FO-ILEs, olive oil (OO)-ILEs, medium-chain triglyceride (MCT)/soybean oil (SO)-ILEs, and pure SO-ILEs. Data were statistically combined through Bayesian NMA and the Surface Under the Cumulative RAnking (SUCRA) was calculated for all outcomes. RESULTS 1651 publications were retrieved in the original search, 47 RCTs were included in the NMA. For FO-ILEs, very highly credible reductions in infection risk versus SO-ILEs [odds ratio (OR) = 0.43 90% credibility interval (CrI) (0.29-0.63)], MCT/soybean oil-ILEs [0.59 (0.43-0.82)], and OO-ILEs [0.56 (0.33-0.91)], and in sepsis risk versus SO-ILEs [0.22 (0.08-0.59)], as well as substantial reductions in hospital length of stay versus SO-ILEs [mean difference (MD) = -2.31 (-3.14 to -1.59) days] and MCT/SO-ILEs (-2.01 (-2.82 to -1.22 days) were shown. According to SUCRA score, FO-ILEs were ranked first for all five outcomes. CONCLUSIONS In hospitalized patients, FO-ILEs provide significant clinical benefits over all other types of ILEs, ranking first for all outcomes investigated. REGISTRATION NO PROSPERO 2022 CRD42022328660.
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Affiliation(s)
| | - Konstantin Mayer
- Department of Internal Medicine, Pneumology and Sleep Medicine, ViDia Kliniken, Karlsruhe, University Hospital of Giessen and Marburg, Giessen, Germany.
| | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, 31-115 Krakow, Poland.
| | - Martin D Rosenthal
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
| | | | - Axel R Heller
- Department of Anaesthesiology and Intensive Care Medicine, University of Augsburg, Augsburg, Germany.
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Förch A, Deetjen P, Heller AR. [Dysnatremia]. Anaesthesiologie 2023; 72:293-306. [PMID: 36995370 DOI: 10.1007/s00101-023-01273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/31/2023]
Abstract
Changes in serum sodium concentrations are frequently encountered by anesthesiologists, are complex and are often inadequately treated. Feared consequences include neurological complications, such as cerebral hemorrhage, cerebral edema and coma. Dysnatremia is always accompanied disturbances in the water balance. Accordingly, these are routinely classified based on the tonicity; however, in the daily routine and especially in the acute setting, the volume status and extracellular volume are often difficult to assess. Severe symptomatic hyponatremia with impending cerebral edema is treated by administration of hypertonic saline solution. If the rise in serum sodium is too rapid, there is a risk of central pontine myelinolysis. In a second step, the cause of the hyponatremia can be investigated and the appropriate treatment can be initiated. In the case of hypernatremia, the etiology of the disorder must be clarified before treatment. The goal is to compensate for the water deficiency by correcting the cause, specific volume therapy and, if necessary, drug support. A slow and controlled compensation must be closely monitored in order to avoid neurological complications. An algorithm has been developed that provides an overview of the dysnatremias, aids with making the diagnosis and gives recommendations for treatment measures in the clinical routine.
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Affiliation(s)
- Anna Förch
- Klinik für Anästhesie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Phillip Deetjen
- Klinik für Anästhesie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - Axel R Heller
- Klinik für Anästhesie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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9
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Heller AR, Eberlein-Gonska M, Held HC, Koch T. [Systematic risk management for a planned gas shutdown in the high-care facility of a university hospital]. Anaesthesiologie 2023; 72:282-292. [PMID: 36754868 PMCID: PMC10076373 DOI: 10.1007/s00101-023-01254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/23/2022] [Accepted: 12/25/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the course of building extension works at Dresden University Hospital, it was necessary to shut down the central medical gas supply in a building with 3 intensive care wards with 22 beds, an operating theater tract with 5 operating rooms and 6 normal wards each with 28 beds during ongoing services. Thus, for the construction phase there was a need to establish an interim decentralized gas supply with zero failure tolerance for the affected functional units . METHODS Following established procedures for possible risk and failure analysis, a project group was set up by the hospital's emergency and disaster management officer to develop a project plan, a needs assessment and a communication plan. RESULTS A variety of risk factors were systematically identified for which appropriate countermeasures needed to be designed. The needs assessment over 4 h based on physiological parameters for the maximum available 22 ventilator beds resulted in 26,000 l of oxygen and 26,000 l of compressed air. A total of 7 supply points were each equipped with two 50l cylinders for both oxygen and compressed air, with a total availability of 175,000 l of each of the 2 gases. Another eight cylinders each were held in reserve. The project was carried out on a Saturday without an elective surgery program, so that the operating rooms concerned could be closed. The timing was chosen so that double staffing of intensive care personnel was available during the afternoon shift change. In advance, as many of the patients on mechanical ventilation as possible were transferred within the hospital; however, nine of the mechanically ventilated patients had to remain. The technical intervention in the gas supply lasted only 2 h without affecting the patient's condition. During the 2‑h interim supply, 16,500 l of compressed air and 8000 l of oxygen were consumed on the high-care wards. The calculated hourly consumption per ventilated patient was 917 l of air (15 l/min) and 444 l of oxygen (7 l/min). The quantity framework based on empirical values from intensive care medicine was significantly lower. This was more than compensated for by the 10-fold stocking of gas and the predictably lower number of ventilated patients than the maximum occupancy used as a basis. CONCLUSION For technical interventions in high-risk areas, careful planning and execution in an effective team is required. Established procedures of project management and risk assessment help to avoid errors.
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Affiliation(s)
- Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland. .,Klinik und Poliklinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Dresden, Dresden, Deutschland. .,medizinischer Katastrophenschutzbeauftragter, Universitätsklinikum Dresden, Dresden, Deutschland.
| | - Maria Eberlein-Gonska
- Qualitäts- und Medizinisches Risikomanagement, Universitätsklinikum Dresden, Dresden, Deutschland
| | - Hanns C Held
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Dresden, Dresden, Deutschland
| | - Thea Koch
- Klinik und Poliklinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Dresden, Dresden, Deutschland
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10
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Heller AR, Bolkenius D. [Climate protection: open technology initiative from users and manufacturers necessary]. Anaesthesiologie 2023; 72:63-64. [PMID: 36592187 DOI: 10.1007/s00101-022-01242-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/03/2023]
Affiliation(s)
- A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - D Bolkenius
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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11
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Bartenschlager CC, Ebel SS, Kling S, Vehreschild J, Zabel LT, Spinner CD, Schuler A, Heller AR, Borgmann S, Hoffmann R, Rieg S, Messmann H, Hower M, Brunner JO, Hanses F, Römmele C. COVIDAL: A machine learning classifier for digital COVID-19 diagnosis in German hospitals. ACM Trans Manage Inf Syst 2022. [DOI: 10.1145/3567431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For the fight against the COVID-19 pandemic, it is particularly important to map the course of infection, in terms of patients who have currently tested SARS-CoV-2 positive, as accurately as possible. In hospitals, this is even more important because resources have become scarce. Although polymerase chain reaction (PCR) and point of care (POC) antigen testing capacities have been massively expanded, they are often very time-consuming and cost-intensive and, in some cases, lack appropriate performance. To meet these challenges, we propose the COVIDAL classifier for AI-based diagnosis of symptomatic COVID-19 subjects in hospitals based on laboratory parameters. We evaluate the algorithm's performance by unique multicenter data with approx. 4,000 patients and an extraordinary high ratio of SARS-CoV-2 positive patients. We analyze the influence of data preparation, flexibility in optimization targets as well as the selection of the test set on the COVIDAL outcome. The algorithm is compared with standard AI, PCR, POC antigen testing and manual classifications of seven physicians by a decision theoretic scoring model including performance metrics, turnaround times and cost. Thereby, we define health care settings in which a certain classifier for COVID-19 diagnosis is to be applied. We find sensitivities, specificities and accuracies of the COVIDAL algorithm of up to 90 percent. Our scoring model suggests using PCR testing for a focus on performance metrics. For turnaround times, POC antigen testing should be used. If balancing performance, turnaround times and cost is of interest, as, for example, in the emergency department, COVIDAL is superior based on the scoring model.
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Affiliation(s)
- Christina C. Bartenschlager
- Chair of Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159 Augsburg, Germany
| | - Stefanie S. Ebel
- Chair of Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159 Augsburg, Germany
| | - Sebastian Kling
- Chair of Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159 Augsburg, Germany
| | - Janne Vehreschild
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt am Main, Germany; Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Lutz T. Zabel
- Laboratory Medicine, Alb Fils Kliniken GmbH, Eichertstraße 3, 73035 Göppingen, Germany
| | - Christoph D. Spinner
- Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Department of Internal Medicine II, Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas Schuler
- Gastroenterology, Alb Fils Kliniken GmbH, Eichertstraße 3, 73035 Göppingen, Germany
| | - Axel R. Heller
- Anaesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | | | - Reinhard Hoffmann
- Laboratory Medicine and Microbiology, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Siegbert Rieg
- Clinic for Internal Medicine II - Infectiology, University Hospital Freiburg, Germany
| | - Helmut Messmann
- Clinic for Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Martin Hower
- Department of Pneumology, Infectious Diseases and Intensive Care, Klinikum Dortmund gGmbH, Hospital of University Witten / Herdecke, 44137 Dortmund, Germany
| | - Jens O. Brunner
- Chair of Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstraße 16, 86159 Augsburg, Germany
| | - Frank Hanses
- Emergency Department, University Hospital Regensburg, Germany; Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Germany
| | - Christoph Römmele
- Clinic for Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
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12
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Heller AR, Breuer G, Sander M. [Anesthesiological intensive care medicine : The series "Medical specialist training anesthesiology" is continued…]. Anaesthesiologie 2022; 71:1-2. [PMID: 36006422 DOI: 10.1007/s00101-022-01182-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Georg Breuer
- Klinik für Anästhesiologie und Operative Intensivmedizin, REGIOMED-Klinikum Coburg GmbH, Ketschendorfer Str. 33, 96450, Coburg, Deutschland.
| | - Michael Sander
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, UKGM GmbH, Justus-Liebig-Universität Gießen, Rudolf-Buchheim Str. 7, 35392, Gießen, Deutschland.
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13
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Bartenschlager CC, Brunner JO, Heller AR. [Evaluation of score-based approaches for ex post triage in intensive care units during the COVID-19 pandemic: a simulation-based analysis]. Notf Rett Med 2022; 25:221-223. [PMID: 35542759 PMCID: PMC9073506 DOI: 10.1007/s10049-022-01035-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Christina C Bartenschlager
- Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159 Augsburg, Deutschland
| | - Jens O Brunner
- Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159 Augsburg, Deutschland
| | - Axel R Heller
- Present Address: Klinik für Anaesthesie und Operative Intensivmedizin, Medizinische Fakultät, Universitätsklinikum Augsburg, Universität Augsburg, Stenglinstr. 2, 86156 Augsburg, Deutschland.,Zweckverband für Rettungsdienst und Feuerwehralarmierung Augsburg, Stenglinstr. 2, 86156 Augsburg, Deutschland
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14
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Ring J, Beyer K, Bircher A, Biedermann T, Fischer M, Fuchs T, Heller AR, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Ruëff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Kurzfassung der Leitlinie "Akuttherapie und Management der Anaphylaxie - Update 2021" für Patienten und Angehörige. Allergo J 2021; 30:24-31. [PMID: 34744321 PMCID: PMC8560215 DOI: 10.1007/s15007-021-4907-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Johannes Ring
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Kirsten Beyer
- Charité Universitätsmedizin Berlin, Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Korea
| | - Andreas Bircher
- Allergologische Poliklinik, Klinik für -Dermatologie,, Universitätsspital Basel, Basel, Schweiz
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München, München, Germany
| | - Matthias Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ALB FILS Kliniken Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Klinik f. Dermatologie, Venerologie u. Allergologie, Georg-August-Universität, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Kinderklinik und Kinderpoliklinik im Dr. von Hauner'schen Kinderspital, Ludwig-Maximilians-Universität München, München, Germany
| | - Isidor Huttegger
- Klinik für Pädiatrie, Universitätsklinikum Salzburg, Salzburg, Österreich
| | - Thilo Jakob
- Universitätsklinikum Gießen, Klinik für Dermatologie, Venerologie und Allergologie, Gaffkystraße 14, 35392 Gießen, Germany
| | - Ludger Klimek
- FA für Dermatologie u. Allergologie, Zentrum f. Rhinologie und Allergologie, An den Quellen 10, 65183 Wiesbaden, Germany
| | - Matthias V Kopp
- Klinik für Kinder- und Jugendmedizin, UKSH Campus Lübeck, Lübeck, Germany
| | - Claudia Kugler
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München, München, Germany
| | - Lars Lange
- Abteilung für Kinder- und Judendmedizin, GFO-Kliniken Bonn - Betriebsstätte St. Marien, Robert-Koch-Str. 1, 53115 Bonn, Germany
| | - Oliver Pfaar
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Sektion Rhinologie und Allergo-logie,, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Ernst Rietschel
- Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Köln, Köln, Germany
| | - Franziska Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie, Klinikum der Ludwig--Maximilians-Universität München, München, Germany
| | - Sabine Schnadt
- Deutscher Allergie- und Asthmabund (DAAB), An der Eickesmühle 15 - 19, 41238 Mönchengladbach, Germany
| | - Roland Seifert
- Institut für Pharmakologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Britta Stöcker
- Praxis für Kinderheilkunde und Jugendmedizin, Bonn, Germany
| | - Regina Treudler
- Universitätsklinikum Leipzig, Klinik f. Dermatologie u. Allergologie, Philipp-Rosenthal-Str. 23, 4103 Leipzig, Germany
| | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Univ.-Klinikum Carl Gustav Carus, Fetscherstraße 74, 1307 Dresden, Germany
| | - Thomas Werfel
- Klinik für Dermatologie, Allergologie und Venerologie, Med. Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Margitta Worm
- Klinik für Dermatologie und Allergologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Helmut Sitter
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Knut Brockow
- Technische Universität München, Klinik f. Dermatologie und Allergologie am Biederstein, Biedersteiner Str. 29, 80802 München, Germany
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Uhlig C, Vicent O, Spieth S, Ludwig S, Reeps C, Heller AR, Thea K, Spieth PM, Rössel T. Influence of Anatomic Conditions on Efficacy and Safety of Combined Intermediate Cervical Plexus Block and Perivascular Infiltration of Internal Carotid Artery in Carotid Endarterectomy: A Prospective Observational Trial. Ultrasound Med Biol 2021; 47:2890-2902. [PMID: 34325958 DOI: 10.1016/j.ultrasmedbio.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/22/2021] [Accepted: 05/11/2021] [Indexed: 06/13/2023]
Abstract
Ultrasound-guided intermediate cervical plexus blockade with perivascular infiltration of the carotid artery bifurcation perivacular block (PVB) is a reliable technique for regional anesthesia in carotid endarterectomy (CEA). We investigated the effect of the carotid bifurcation level (CBL) on PVB efficacy and safety in patients undergoing CEA. This prospective observational cohort study included 447 consecutive CEA patients who received PVB over a 6-y period. Vascular and neurologic puncture-related complications were recorded. The CBL was localized at the low level (C4 and C5 vertebra, low-level [LL] group) in 381 (85.2%) patients and at the high level (C2 and C3 vertebra, high-level [HL] group) in 66 (14.8%) patients. Local anesthetic supplementation by surgeons was necessary in 64 (14.3%) patients in the LL group and 38 (59.4%) patients in the HL group (p < 0.001) and was associated with a higher rate of central neurologic complications in the HL group (p = 0.031). Therefore, the efficacy of the PVB may be influenced by the CBL.
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Affiliation(s)
- Christopher Uhlig
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany; Department of Cardiac Anesthesiology, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Oliver Vicent
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Stephanie Spieth
- Department of Radiology, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Stefan Ludwig
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Axel R Heller
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany; Department of Anesthesiology and Surgical Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Koch Thea
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany.
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16
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Worm M, Ring J, Klimek L, Jakob T, Lange L, Treudler R, Beyer K, Werfel T, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller AR, Hoffmann F, Huttegger I, Kopp MV, Kugler C, Lommatzsch M, Pfaar O, Rietschel E, Ruëff F, Schnadt S, Seifert R, Stöcker B, Vogelberg C, Sitter H, Gieler U, Brockow K. Management des Anaphylaxie-Risikos bei Covid-19-Impfung. HNO Nachrichten 2021; 51:18-21. [PMID: 33619418 PMCID: PMC7890774 DOI: 10.1007/s00060-021-7480-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Margitta Worm
- Charité – Universitätsmedizin Berlin, Allergologie und Immunologie, Klinik für Dermatologie und Allergologie, Charitéplatz 1, 10117 Berlin, Germany
| | - Johannes Ring
- Technische Universität München, Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein,, München, Germany
| | - Ludger Klimek
- Charité – Universitätsmedizin Berlin, Allergologie und Immunologie, Klinik für Dermatologie und Allergologie, Charitéplatz 1, 10117 Berlin, Germany
| | - Thilo Jakob
- Universitäts-Hautklinik Gießen, Gießen, Schweiz
| | | | - Regina Treudler
- Klinik für Dermatologie und Allergologie, Universitätsmedizin Leipzig, Leipzig, Germany
| | - Kirsten Beyer
- Technische Universität München, Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein,, Berlin, Germany
| | - Thomas Werfel
- Medizinische Hochschule Hannover, Klinik und Poliklinik für Dermatologie und Allergologie, Hannover, Germany
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein,, Technische Universität München, München, Germany
| | - Andreas Bircher
- Allergologische Poliklinik, Klinik für Dermatologie,, Universitätsspital Basel, Basel, Schweiz
| | - Matthias Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ALB FILS Kliniken Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Hautklinik Universitätsmedizin Göttingen, Göttingen, Germany
| | - Axel R. Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Kinderklinik und Kinderpoliklinik im Dr. von Hauner‘schen Kinderspital, Ludwig-Maximilians-Universität München, München, Germany
| | - Isidor Huttegger
- Klinik für Pädiatrie, Universitätsklinikum Salzburg, Salzburg, Österreich
| | - Matthias Volkmar Kopp
- Sektion für Pädiatrische Pneumologie und Allergologie, Universitätsklinikum Lübeck, Lübeck, Germany
| | - Claudia Kugler
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München, München, Österreich
| | - Marek Lommatzsch
- Klinik für Pneumologie, Universitätsklinikum Rostock, Rostock, Germany
| | - Oliver Pfaar
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Sektion Rhinologie und Allergologie,, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Ernst Rietschel
- Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Köln, Köln, Germany
| | - Franziska Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie, Klinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Sabine Schnadt
- Deutscher Allergie- und Asthmabund e. V. (DAAB), Mönchengladbach, Germany
| | - Roland Seifert
- Institut für Pharmakologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Britta Stöcker
- Praxis für Kinderheilkunde und Jugendmedizin, Bonn, Germany
| | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Helmut Sitter
- Institut für chirurgische Forschung, Philipps-Universität Marburg, Marburg, Germany
| | - Uwe Gieler
- Klinik für Psychosomatik, Vitos-Klinik Giessen-Marburg und Univ. Hautklinik Gießen, Gießen, Germany
| | - Knut Brockow
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein,, Technische Universität München, München, Germany
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17
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Worm M, Ring J, Klimek L, Jakob T, Lange L, Treudler R, Beyer K, Werfel T, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller AR, Hoffmann F, Huttegger I, Kopp MV, Kugler C, Lommatzsch M, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Vogelberg C, Sitter H, Gieler U, Brockow K. [Covid-19 vaccination and risk of anaphylaxis - Recommendations for practical management]. MMW Fortschr Med 2021; 163:48-51. [PMID: 33464512 PMCID: PMC7814269 DOI: 10.1007/s15006-021-9530-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- Margitta Worm
- Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Pradelli L, Klek S, Mayer K, Omar Alsaleh AJ, Rosenthal MD, Heller AR, Muscaritoli M. Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis. Crit Care 2020; 24:634. [PMID: 33143750 PMCID: PMC7607851 DOI: 10.1186/s13054-020-03356-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/23/2020] [Indexed: 12/26/2022]
Abstract
Background Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.
Methods We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses. Results In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (− 3.05 days; 95% CI − 5.03, − 1.07; p = 0.003) and ICU length of stay (LOS) (− 1.89 days; 95% CI − 3.33, − 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (− 3.98 days; 95% CI − 6.90, − 1.06; p = 0.008) and ICU LOS (− 2.14 days; 95% CI − 3.89, − 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US. Conclusion These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.
Study registration PROSPERO CRD42019129311.
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Affiliation(s)
- Lorenzo Pradelli
- AdRes-Health Economics and Outcome Research, Via Vittorio Alfieri 17, 10121, Turin, Italy.
| | - Stanislaw Klek
- Department of General and Oncology Surgery With Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Tyniecka 15, 32-050, Skawina, Poland
| | - Konstantin Mayer
- Medical Clinic 4, Pneumology and Sleep Medicine, ViDia Hospitals Karlsruhe, Südendstr. 32, 76137, Karlsruhe, Germany
| | | | - Martin D Rosenthal
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610-0019, USA
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University of Augsburg, Universitätsstraße 2, 86159, Augsburg, Germany
| | - Maurizio Muscaritoli
- Department of Clinical Medicine, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, RM, Italy
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19
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Römmele C, Neidel T, Heins J, Heider S, Otten V, Ebigbo A, Weber T, Müller M, Spring O, Braun G, Wittmann M, Schoenfelder J, Heller AR, Messmann H, Brunner JO. [Bed capacity management in times of the COVID-19 pandemic : A simulation-based prognosis of normal and intensive care beds using the descriptive data of the University Hospital Augsburg]. Anaesthesist 2020; 69:717-725. [PMID: 32821955 PMCID: PMC7441598 DOI: 10.1007/s00101-020-00830-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Following the regional outbreak in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread all over the world, presenting the healthcare systems with huge challenges worldwide. In Germany the coronavirus diseases 2019 (COVID-19) pandemic has resulted in a slowly growing demand for health care with a sudden occurrence of regional hotspots. This leads to an unpredictable situation for many hospitals, leaving the question of how many bed resources are needed to cope with the surge of COVID-19 patients. OBJECTIVE In this study we created a simulation-based prognostic tool that provides the management of the University Hospital of Augsburg and the civil protection services with the necessary information to plan and guide the disaster response to the ongoing pandemic. Especially the number of beds needed on isolation wards and intensive care units (ICU) are the biggest concerns. The focus should lie not only on the confirmed cases as the patients with suspected COVID-19 are in need of the same resources. MATERIAL AND METHODS For the input we used the latest information provided by governmental institutions about the spreading of the disease, with a special focus on the growth rate of the cumulative number of cases. Due to the dynamics of the current situation, these data can be highly variable. To minimize the influence of this variance, we designed distribution functions for the parameters growth rate, length of stay in hospital and the proportion of infected people who need to be hospitalized in our area of responsibility. Using this input, we started a Monte Carlo simulation with 10,000 runs to predict the range of the number of hospital beds needed within the coming days and compared it with the available resources. RESULTS Since 2 February 2020 a total of 306 patients were treated with suspected or confirmed COVID-19 at this university hospital. Of these 84 needed treatment on the ICU. With the help of several simulation-based forecasts, the required ICU and normal bed capacity at Augsburg University Hospital and the Augsburg ambulance service in the period from 28 March 2020 to 8 June 2020 could be predicted with a high degree of reliability. Simulations that were run before the impact of the restrictions in daily life showed that we would have run out of ICU bed capacity within approximately 1 month. CONCLUSION Our simulation-based prognosis of the health care capacities needed helps the management of the hospital and the civil protection service to make reasonable decisions and adapt the disaster response to the realistic needs. At the same time the forecasts create the possibility to plan the strategic response days and weeks in advance. The tool presented in this study is, as far as we know, the only one accounting not only for confirmed COVID-19 cases but also for suspected COVID-19 patients. Additionally, the few input parameters used are easy to access and can be easily adapted to other healthcare systems.
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Affiliation(s)
- C Römmele
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - T Neidel
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - J Heins
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
- Universitäres Zentrum für Gesundheitswissenschaften am Klinikum Augsburg (UNIKA-T), Wirtschaftswissenschaftliche Fakultät, Universität Augsburg, Neusässer Straße 47, 86159, Augsburg, Deutschland.
| | - S Heider
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
- Universitäres Zentrum für Gesundheitswissenschaften am Klinikum Augsburg (UNIKA-T), Wirtschaftswissenschaftliche Fakultät, Universität Augsburg, Neusässer Straße 47, 86159, Augsburg, Deutschland
| | - V Otten
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - A Ebigbo
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - T Weber
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - M Müller
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - O Spring
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - G Braun
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - M Wittmann
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - J Schoenfelder
- Universitäres Zentrum für Gesundheitswissenschaften am Klinikum Augsburg (UNIKA-T), Wirtschaftswissenschaftliche Fakultät, Universität Augsburg, Neusässer Straße 47, 86159, Augsburg, Deutschland
| | - A R Heller
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
- Führungsgruppe Katastrophenschutz, Zweckverband Rettungsdienst und Feuerwehralarmierung Augsburg, 86143, Augsburg, Deutschland
| | - H Messmann
- Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - J O Brunner
- Universitäres Zentrum für Gesundheitswissenschaften am Klinikum Augsburg (UNIKA-T), Wirtschaftswissenschaftliche Fakultät, Universität Augsburg, Neusässer Straße 47, 86159, Augsburg, Deutschland
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20
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Heller AR, Breuer G. [Medical specialist training anesthesiology-the second special issue is ready! : 25 further practically relevant case examples combined with well-founded background knowledge]. Anaesthesist 2020; 68:199-200. [PMID: 31701174 DOI: 10.1007/s00101-019-00689-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - G Breuer
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Coburg GmbH, Ketschendorfer Str. 33, 96450, Coburg, Deutschland.
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21
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Hölz W, Ackermann S, Zinsmeister T, Heller AR. [82-year-old female with periprosthetic femoral fracture and the need for postoperative monitoring : Preparation for the medical specialist examination: part 26]. Anaesthesist 2020; 68:201-205. [PMID: 31624888 DOI: 10.1007/s00101-019-00658-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- W Hölz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - S Ackermann
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - T Zinsmeister
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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22
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Pradelli L, Klek S, Mayer K, Omar Alsaleh AJ, Rosenthal MD, Heller AR, Muscaritoli M. Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US. JPEN J Parenter Enteral Nutr 2020; 45:999-1008. [PMID: 32713007 PMCID: PMC8451886 DOI: 10.1002/jpen.1972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 01/17/2023]
Abstract
Background ω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US. Methods This pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses. Results Overall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively). Conclusion This cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.
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Affiliation(s)
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Konstantin Mayer
- ViDia Hospitals, Department of Pulmonary and Sleep Medicine, Karlsruhe, Germany
| | | | - Martin D Rosenthal
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University of Augsburg, Augsburg, Germany
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23
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Breuer G, Heller AR. [Specialist medical training in anesthesiology-a special issue for assistant and specialist physicians! : Practical case examples combined with well-founded background knowledge]. Anaesthesist 2020; 68:77-78. [PMID: 30989310 DOI: 10.1007/s00101-019-0584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- G Breuer
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Coburg GmbH, Ketschendorfer Str. 33, 96450, Coburg, Deutschland.
| | - A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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24
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Erratum: DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“. Aktuel Ernahrungsmed 2019. [DOI: 10.1055/a-1022-1588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel
| | - Wolfgang H. Hartl
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München – Klinikum der Universität, Campus Großhadern, München
| | | | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen
| | - Thomas W. Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching, Neuperlach und Schwabing, Städtisches Klinikum München GmbH, München
| | - Tobias Graf
- Universitäres Herzzentrum Lübeck – Medizinische Klinik II/Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Axel R. Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität Augsburg, Augsburg
| | - Ulrich Kampa
- Klinik für Anästhesiologie und Intensivmedizin, Ev. Krankenhaus Hattingen, Hattingen
| | - Konstantin Mayer
- Zentrum für Innere Medizin, Medizinische Klinik II, Universtitätsklinikum Gießen und Marburg, University of Giessen Lung Center, Standort Gießen, Gießen
| | - Elke Muhl
- Eichhörnchenweg 7, 23627 Gross Grönau
| | - Bernd Niemann
- Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen
| | - Andreas Rümelin
- Klinik für Anästhesie und operative Intensivmedizin, HELIOS St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen
| | - Stephan Steiner
- Abteilung für Kardiologie, Pneumologie und Internistische Intensivmedizin, St. Vincenz-Krankenhaus, Limburg
| | - Christian Stoppe
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie
, Klinikum St. Georg gGmbH, Leipzig
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25
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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26
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Pradelli L, Mayer K, Klek S, Omar Alsaleh AJ, Clark RAC, Rosenthal MD, Heller AR, Muscaritoli M. ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis. JPEN J Parenter Enteral Nutr 2019; 44:44-57. [PMID: 31250474 PMCID: PMC7003746 DOI: 10.1002/jpen.1672] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/03/2019] [Indexed: 12/29/2022]
Abstract
This systematic review and meta-analysis investigated ω-3 fatty-acid enriched parenteral nutrition (PN) vs standard (non-ω-3 fatty-acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω-3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω-3 fatty-acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49-0.72; P < 0.00001). Patients given ω-3 fatty-acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42-3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36-2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω-3 fatty-acid enriched PN (RR 0.44, 95% CI 0.28-0.70; P = 0.0004). Mortality rate (co-primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65-1.07; P = 0.15) for the ω-3 fatty-acid enriched group. In summary, ω-3 fatty-acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω-3-enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN.
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Affiliation(s)
| | - Konstantin Mayer
- Department of Internal Medicine, University Hospital of Giessen and Marburg, Giessen, Germany
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | | | - Martin D Rosenthal
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Axel R Heller
- Department of Anaesthesiology and Intensive Care Medicine, University of Augsburg, Augsburg, Germany
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. [DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version]. Anasthesiol Intensivmed Notfallmed Schmerzther 2019; 54:63-73. [PMID: 30620956 DOI: 10.1055/a-0805-4118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process. RESULTS The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices. CONCLUSION The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).
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Standl T, Annecke T, Cascorbi I, R. Heller A, Sabashnikov A, Teske W. The Nomenclature, Definition and Distinction of Types of Shock. Dtsch Arztebl Int 2018; 115:757-768. [PMID: 30573009 PMCID: PMC6323133 DOI: 10.3238/arztebl.2018.0757] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 09/28/2017] [Accepted: 08/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND A severe mismatch between the supply and demand of oxygen is the common feature of all types of shock. We present a newly developed, clinically oriented classification of the various types of shock and their therapeutic implications. METHODS This review is based on pertinent publications (1990-2018) retrieved by a selective search in PubMed, and on the relevant guidelines and meta-analyses. RESULTS There are only four major categories of shock, each of which is mainly related to one of four organ systems. Hypovolemic shock relates to the blood and fluids compartment while distributive shock relates to the vascular system; cardiogenic shock arises from primary cardiac dysfunction; and obstructive shock arises from a blockage of the circulation. Hypovolemic shock is due to intravascular volume loss and is treated by fluid replacement with balanced crystalloids. Distributive shock, on the other hand, is a state of relative hypovolemia resulting from pathological redistribution of the absolute intravascular volume and is treated with a combination of vasoconstrictors and fluid replacement. Cardiogenic shock is due to inadequate function of the heart, which shall be treated, depending on the situation, with drugs, surgery, or other interventional procedures. In obstructive shock, hypoperfusion due to elevated resistance shall be treated with an immediate life-saving intervention. CONCLUSION The new classification is intended to facilitate the goal-driven treatment of shock in both the pre-hospital and the inpatient setting. A uniform treatment strategy should be established for each of the four types of shock.
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Affiliation(s)
- Thomas Standl
- Department of Anesthesiology, Intensive and Palliative Care Medicine, Städtisches Klinikum Solingen gGmbH
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne
| | - Ingolf Cascorbi
- Institute of Clinical and Experimental Pharmacology at the University Medical Center Schleswig-Holstein, Campus Kiel
| | - Axel R. Heller
- Surgical Center/Emergency Department, Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Cardiac Center, University Hospital of Cologne
| | - Wolfram Teske
- Department of Orthopedics and Trauma Surgery, Kath. Krankenhaus Hagen gGmbH
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“. Aktuel Ernahrungsmed 2018. [DOI: 10.1055/a-0713-8179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Zusammenfassung
Fragestellung Die enterale und parenterale Ernährungstherapie kritisch kranker Patienten kann u. a. durch den Zeitpunkt des Beginns, die Wahl des Applikationswegs, die Menge und Zusammensetzung der Makro- und Mikronährstoffzufuhr sowie der Wahl spezieller, immunmodulierender Nährsubstrate variieren. Die Durchführung der Ernährungstherapie nimmt Einfluss auf den klinischen Ausgang dieser Patienten. Ziel der vorliegenden Leitlinie ist es, aktualisierte konsensbasierte Empfehlungen zur klinischen Ernährung kritisch kranker, erwachsener Patienten, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden, zu geben.
Methodik Die früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) wurden in Einklang mit den aktuellen Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) als S2k-Leitlinie aktualisiert. Entsprechend der S2k-Klassifikation dieser Leitlinie enthalten die dargestellten Empfehlungen keine Angabe von Evidenz- und Empfehlungsgraden, da keine systematische Aufbereitung der Evidenz zugrunde gelegt wurde. Als Grundlage für die Empfehlungen wurden insbesondere die seit Erscheinen der letzten DGEM-Leitlinien Intensivmedizin publizierten randomisiert-kontrollierten Studien und Metaanalysen, Beobachtungsstudien mit angemessener Fallzahl und hoher methodologischer Qualität (bis Mai 2018) sowie aktuell gültige Leitlinien anderer Fachgesellschaften herangezogen und kommentiert. Die Empfehlungsstärke ist rein sprachlich beschrieben. Jede Empfehlung wurde mittels Delphi-Verfahren abschließend bewertet und konsentiert.
Ergebnisse Die Leitlinie beschreibt einführend die pathophysiologischen Konsequenzen einer kritischen Erkrankung, welche den Metabolismus und die Ernährbarkeit der Patienten beeinflussen können, ferner die Definitionen unterschiedlicher Erkrankungsphasen im Krankheitsverlauf und sie diskutiert methodologische Aspekte zu ernährungsmedizinischen Studien. In der Folge werden 69 konsentierte Empfehlungen zu wesentlichen, praxisrelevanten Elementen der klinischen Ernährung kritisch kranker Patienten gegeben, darunter die Beurteilung des Ernährungszustands, die Indikation für die klinische Ernährungstherapie, der Beginn und Applikationsweg der Nahrungszufuhr, die Menge und Art der zugeführten Substrate (Makro- und Mikronährstoffe) sowie ernährungstherapeutische Besonderheiten bei adipösen kritisch kranken Patienten und Patienten mit mechanischen Unterstützungssystemen.
Schlussfolgerung Mit der Leitlinie werden aktuelle Handlungsempfehlungen zur enteralen und parenteralen Ernährung erwachsener Patienten geben, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden. Die Gültigkeit der Leitlinie beträgt voraussichtlich 5 Jahre (2018 – 2023).
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Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel
| | - Wolfgang H. Hartl
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München – Klinikum der Universität, Campus Großhadern, München
| | | | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen
| | - Thomas W. Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching, Neuperlach und Schwabing, Städtisches Klinikum München GmbH, München
| | - Tobias Graf
- Universitäres Herzzentrum Lübeck – Medizinische Klinik II/Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Axel R. Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität Augsburg, Augsburg
| | - Ulrich Kampa
- Klinik für Anästhesiologie und Intensivmedizin, Ev. Krankenhaus Hattingen, Hattingen
| | - Konstantin Mayer
- Zentrum für Innere Medizin, Medizinische Klinik II, Universtitätsklinikum Gießen und Marburg, University of Giessen Lung Center, Standort Gießen, Gießen
| | - Elke Muhl
- Eichhörnchenweg 7, 23627 Gross Grönau
| | - Bernd Niemann
- Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen
| | - Andreas Rümelin
- Klinik für Anästhesie und operative Intensivmedizin, HELIOS St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen
| | - Stephan Steiner
- Abteilung für Kardiologie, Pneumologie und Internistische Intensivmedizin, St. Vincenz-Krankenhaus, Limburg
| | - Christian Stoppe
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie
, Klinikum St. Georg gGmbH, Leipzig
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Schewe JC, Lenkeit S, Ganser J, Heller AR, Koch T. [Implementation of Medical Emergency Teams to Improve Perioperative Patient Safety. Who? When? How?]. Zentralbl Chir 2018; 145:426-431. [PMID: 29972850 DOI: 10.1055/a-0631-4867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In contrast to prehospital emergency medicine, there are no comparable established structures or statutory requirements for structural and procedural organisation, or qualification of personnel and equipment for in-hospital emergency care in Germany. However, in perioperative patients, unexpected complications are fairly common on regular wards. Often, even hours before a possible critical event, warning signs of deterioration are present, which too often go unnoticed. Subsequently, potentially avoidable serious complications or cardiac arrest may occur. The establishment of so-called medical emergency teams (MET) serves to improve the emergency care organisation of the hospital and helps to avoid in-hospital cardiac arrest. The MET is alerted at an early stage of deterioration and uses a preventive therapy approach for pathophysiological deviations of the vital signs. This preventative approach can help to avoid in-hospital cardiac arrest and unplanned admission to an intensive care unit and thus contribute to increase perioperative patient safety.
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Affiliation(s)
- Jens-Christian Schewe
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Stefan Lenkeit
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Janina Ganser
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Axel R Heller
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Thea Koch
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
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Abstract
Background Camera-based photoplethysmography (cbPPG) is a measurement technique which enables remote vital sign monitoring by using cameras. To obtain valid plethysmograms, proper regions of interest (ROIs) have to be selected in the video data. Most automated selection methods rely on specific spatial or temporal features limiting a broader application. In this work, we present a new method which overcomes those drawbacks and, therefore, allows cbPPG to be applied in an intraoperative environment. Methods We recorded 41 patients during surgery using an RGB and a near-infrared (NIR) camera. A Bayesian skin classifier was employed to detect suitable regions, and a level set segmentation approach to define and track ROIs based on spatial homogeneity. Results The results show stable and homogeneously illuminated ROIs. We further evaluated their quality with regards to extracted cbPPG signals. The green channel provided the best results where heart rates could be correctly estimated in 95.6% of cases. The NIR channel yielded the highest contribution in compensating false estimations. Conclusions The proposed method proved that cbPPG is applicable in intraoperative environments. It can be easily transferred to other settings regardless of which body site is considered. Electronic supplementary material The online version of this article (10.1186/s12938-018-0467-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Trumpp
- Institute of Biomedical Engineering, TU Dresden, Fetscherstraße 29, 01307, Dresden, Germany.
| | - Johannes Lohr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Daniel Wedekind
- Institute of Biomedical Engineering, TU Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Martin Schmidt
- Institute of Biomedical Engineering, TU Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Matthias Burghardt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Hagen Malberg
- Institute of Biomedical Engineering, TU Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Sebastian Zaunseder
- Institute of Biomedical Engineering, TU Dresden, Fetscherstraße 29, 01307, Dresden, Germany
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Abstract
Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.
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Affiliation(s)
- C Eisold
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland.
| | - A R Heller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
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33
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Neidel T, Salvador N, Heller AR. Impact of systolic blood pressure limits on the diagnostic value of triage algorithms. Scand J Trauma Resusc Emerg Med 2017; 25:118. [PMID: 29202769 PMCID: PMC5715557 DOI: 10.1186/s13049-017-0461-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
Background Major incidents are characterized by a lack of resources compared to an overwhelming number of casualties, requiring a prioritization of medical treatment. Triage algorithms are an essential tool for prioritizing the urgency of treatment for patients, but the evidence to support one over another is very limited. We determined the influence of blood pressure limits on the diagnostic value of triage algorithms, considering if pulse should be palpated centrally or peripherally. Methods We used a database representing 500 consecutive HEMS patients. Each patient was allocated a triage category (T1/red, T2/yellow, T3/green) by a group of experienced doctors in disaster medicine, independent of any algorithm. mSTaRT, ASAV, Field Triage Score (FTS), Care Flight (CF), “Model Bavaria” and two Norwegian algorithms (Nor and TAS), all containing the question “Pulse palpable?”, were translated into Excel commands, calculating the triage category for each patient automatically. We used 5 blood pressure limits ranging from 130 to 60 mmHg to determine palpable pulse. The resulting triage categories were analyzed with respect to sensitivity, specificity and Youden Index (J) separately for trauma and non-trauma patients, and for all patients combined. Results For the entire population of patients within all triage algorithms the Youden Index (J) was highest for T1 (J between 0,14 and 0,62). Combining trauma and non-trauma patients, the highest J was obtained by ASAV (J = 0,62 at 60 mmHg). ASAV scored the highest within trauma patients (J = 0,87 at 60 mmHg), whereas Model Bavaria (J = 0,54 at 80 mmHg) reached highest amongst non-trauma patients. FTS performed worst for all patients (J = 0,14 at 60 mmHg), showing a lower score for trauma patients (J = 0,0 at 60 mmHg). Change of blood pressure limits resulted in different diagnostic values of all algorithms. Discussion We demonstrate that differing blood pressure limits have a remarkable impact on diagnostic values of triage algorithms. Further research is needed to determine the lowest blood pressure value that is possible to palpate at a peripheral artery compared to a central artery. Conclusion As a consequence, it might be important in which location pulses are palpated according to the algorithm at hand during triage of patients.
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Affiliation(s)
- Tobias Neidel
- Department of Anesthesiology and Critical Care Medicine, Medical Faculty Carl Gustav Carus, TU-Dresden, Fetscherstrasse 74, D-01307, Dresden, Germany.
| | - Nicolas Salvador
- Department of Anesthesiology and Critical Care Medicine, Medical Faculty Carl Gustav Carus, TU-Dresden, Fetscherstrasse 74, D-01307, Dresden, Germany
| | - Axel R Heller
- Department of Anesthesiology and Critical Care Medicine, Medical Faculty Carl Gustav Carus, TU-Dresden, Fetscherstrasse 74, D-01307, Dresden, Germany
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34
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Abstract
Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.
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Affiliation(s)
- C Eisold
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland.
| | - A R Heller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
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35
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Mirus M, Heller AR. [Diagnostic investigation in emergency medicine: Why case history is crucial]. Anaesthesist 2017; 66:256-264. [PMID: 28194478 DOI: 10.1007/s00101-017-0280-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 12/09/2016] [Accepted: 01/26/2017] [Indexed: 11/29/2022]
Abstract
We present the preclinical case of a patient reporting chest pain. Pain impeded physical examination. Reviewing the patient's detailed medical history after analgesia revealed a connection between the reported pain and vomiting. This led to a suspicion of organ perforation. Thus, the patient was admitted to a surgical emergency room (ER) and Boerhaave's Syndrome was diagnosed. After deterioration in the ER, cardiopulmonal reanimation (CPR), and successful surgical treatment, the patient was transferred to the intensive care unit (ICU) seven hours after first contact.
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Affiliation(s)
- M Mirus
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - A R Heller
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland
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Rössel T, Paul R, Richter T, Ludwig S, Hofmockel T, Heller AR, Koch T. [Management of anesthesia in endovascular interventions]. Anaesthesist 2016; 65:891-910. [PMID: 27900415 DOI: 10.1007/s00101-016-0241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.
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Affiliation(s)
- T Rössel
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - R Paul
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - T Richter
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - S Ludwig
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, TU Dresden, Dresden, Deutschland
| | - T Hofmockel
- Institut und Poliklinik für Radiologische Diagnostik, TU Dresden, Dresden, Deutschland
| | - A R Heller
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - T Koch
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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37
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Affiliation(s)
- Axel R Heller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Uniklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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Abstract
An acute obstruction of blood flow in central vessels of the systemic or pulmonary circulation causes the clinical symptoms of shock accompanied by disturbances of consciousness, centralization, oliguria, hypotension and tachycardia. In the case of an acute pulmonary embolism an intravascular occlusion results in an acute increase of the right ventricular afterload. In the case of a tension pneumothorax, an obstruction of the blood vessels supplying the heart is caused by an increase in extravascular pressure. From a hemodynamic viewpoint circulatory shock caused by obstruction is closely followed by cardiac deterioration; however, etiological and therapeutic options necessitate demarcation of cardiac from non-cardiac obstructive causes. The high dynamics of this potentially life-threatening condition is a hallmark of all types of obstructive shock. This requires an expeditious and purposeful diagnosis and a rapid and well-aimed therapy.
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Affiliation(s)
- H Pich
- Klinik für Anästhesiologie und Intensivtherapie, Medizinische Fakultät Carl Gustav Carus, TU-Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
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Uhlig C, Felbinger T, Heller AR. Comments on Kagan et al.: Preemptive enteral nutrition enriched with eicosapentaenoic acid, gamma-linolenic acid and antioxidants in severe multiple trauma: a prospective, randomized, double-blind study. Intensive Care Med 2015; 41:1513. [PMID: 26109401 DOI: 10.1007/s00134-015-3926-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Christopher Uhlig
- Department of Anesthesiology and Critical Care, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany,
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40
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Müller MP, Poenicke C, Kurth M, Richter T, Koch T, Eisold C, Pfältzer A, Heller AR. Quality of basic life support when using different commercially available public access defibrillators. Scand J Trauma Resusc Emerg Med 2015; 23:48. [PMID: 26094032 PMCID: PMC4475613 DOI: 10.1186/s13049-015-0123-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/14/2015] [Indexed: 01/14/2023] Open
Abstract
Background Basic life support (BLS) guidelines focus on chest compressions with a minimal no-flow fraction (NFF), early defibrillation, and a short perishock pause. By using an automated external defibrillator (AED) lay persons are guided through the process of attaching electrodes and initiating defibrillation. It is unclear, however, to what extent the voice instructions given by the AED might influence the quality of initial resuscitation. Methods Using a patient simulator, 8 different commercially available AEDs were evaluated within two different BLS scenarios (ventricular fibrillation vs. asystole). A BLS certified instructor acted according to the current European Resuscitation Council 2010 Guidelines and followed all of the AED voice prompts. In a second set of scenarios, the rescuer anticipated the appropriate actions and started already before the AED stopped speaking. A BLS scenario without AED served as the control. All scenarios were run three times. Results The time until the first chest compression was 25 ± 2 seconds without the AED and ranged from 50 ± 3 to 148 ± 13 seconds with the AED depending on the model used. The NFF was .26 ± .01 without the AED and between .37 ± .01 and .72 ± .01 when an AED was used. The perishock pause ranged from 12 ± 0 to 46 ± 0 seconds. The optimized sequence of actions reduced the NFF, which ranged now from .32 ± .01 to .41 ± .01, and the perishock pause ranging from 1 ± 1 to 19 ± 1 seconds. Conclusions Voice prompts given by commercially available AED merely meet the requirements of current evidence in basic life support. Furthermore, there is a significant difference between devices with regard to time until the first chest compression, perishock pause, no-flow fraction and other objective measures of the quality of BLS. However, the BLS quality may be improved with optimized handling of the AED. Thus, rescuers should be trained on the respective AED devices, and manufacturers should expend more effort in improving user guidance to shorten the NFF and perishock pause. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0123-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael P Müller
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Cynthia Poenicke
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Maxi Kurth
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Torsten Richter
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Thea Koch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Carolin Eisold
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Adrian Pfältzer
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Axel R Heller
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany.
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Affiliation(s)
- Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Germany
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Heller AR, Heger J, Gama de Abreu M, Müller MP. Cafedrine/theodrenaline in anaesthesia: influencing factors in restoring arterial blood pressure. Anaesthesist 2015; 64:190-6. [PMID: 25757552 PMCID: PMC4383809 DOI: 10.1007/s00101-015-0005-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 11/26/2022]
Abstract
Background Hypotensive states that require fast stabilisation of blood pressure can occur during anaesthesia. In 1963, the 20:1 mixture of cafedrine/theodrenaline (Akrinor®) was introduced in Germany for use in anaesthesia and emergency medicine in the first-line management of hypotensive states. Though on the market for many years, few pharmacodynamic data are available on this combination net beta-mimetic agent. Aim This study aimed to examine the drug combination in real-life clinical practice and recorded time to 10 % mean arterial blood pressure (MAP) increase and heart rate. Furthermore, potential factors that influence drug effectiveness under anaesthesia were assessed. Methods Data were collected within a standardised anaesthesia protocol. A total of 353 consecutive patients (female/male = 149/204) who received cafedrine/theodrenaline after a drop in MAP ≥ 5 % were included in the study. The time to 10 % increase in MAP, dosage of cafedrine/theodrenaline, volume loading, blood pressure and heart rate were monitored over time. Results Patients were a mean (standard deviation) of 64.4 ± 15.1 years old with a baseline MAP of 82 ± 14 mmHg, which dropped to a mean of 63 ± 10 mmHg during anaesthesia without gender differences. Cafedrine/theodrenaline (1.27 ± 1.0 mg/kg; 64 ± 50 µg/kg) significantly increased MAP (p < 0.001) by 11 ± 16 mmHg within 5 min, reaching peak values within 17.4 ± 9.0 min. Heart rate was not affected in a clinically significant manner. Cafedrine/theodrenaline induced a 10 % MAP increase after 7.2 ± 4.6 min (women) and after 8.6 ± 6.3 min (men) (p = 0.018). Independent of gender, the dose of cafedrine/theodrenaline required to achieve the observed MAP increase of 14 ± 16 mmHg at 15 min was significantly different in patients with heart failure [1.78 ± 1.67 mg/kg (cafedrine)/89.0 ± 83.5 µg/kg (theodrenaline)] compared with healthy patients [1.16 ± 0.77 mg/kg (cafedrine)/58.0 ± 38.5 µg/kg (theodrenaline)] (p = 0.005). Concomitant medication with beta-blocking agents significantly prolonged the time to 10 % MAP increase [9.0 ± 7.0 vs. 7.3 ± 4.3 min (p = 0.008)]. Conclusion Cafedrine/theodrenaline quickly restores MAP during anaesthesia. Female gender is associated with higher effectiveness, while heart failure and beta-blocker administration lower the anti-hypotonic effect. Prospective studies in defined patient populations are warranted to further characterise the effect of cafedrine/theodrenaline.
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Affiliation(s)
- A R Heller
- Department of Anaesthesia and Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany,
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Pradelli L, Eandi M, Povero M, Mayer K, Muscaritoli M, Heller AR, Fries-Schaffner E. Cost-effectiveness of omega-3 fatty acid supplements in parenteral nutrition therapy in hospitals: a discrete event simulation model. Clin Nutr 2013; 33:785-92. [PMID: 24345520 DOI: 10.1016/j.clnu.2013.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 11/01/2013] [Accepted: 11/27/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND & AIMS A recent meta-analysis showed that supplementation of omega-3 fatty acids in parenteral nutrition (PN) regimens is associated with a statistically and clinically significant reduction in infection rate, and length of hospital stay (LOS) in medical and surgical patients admitted to the ICU and in surgical patients not admitted to the ICU. The objective of this present study was to evaluate the cost-effectiveness of the addition of omega-3 fatty acids to standard PN regimens in four European countries (Italy, France, Germany and the UK) from the healthcare provider perspective. METHODS Using a discrete event simulation scheme, a patient-level simulation model was developed, based on outcomes from the Italian ICU patient population and published literature. Comparative efficacy data for PN regimens containing omega-3 fatty acids versus standard PN regimens was taken from the meta-analysis of published randomised clinical trials (n = 23 studies with a total of 1502 patients), and hospital LOS reduction was further processed in order to split the reduction in ICU stay from that in-ward stays for patients admitted to the ICU. Country-specific cost data was obtained for Italian, French, German and UK healthcare systems. Clinical outcomes included in the model were death rates, nosocomial infection rates, and ICU/hospital LOS. Probabilistic and deterministic sensitivity analyses were undertaken to test the reliability of results. RESULTS PN regimens containing omega-3 fatty acids were more effective on average than standard PN both in ICU and in non-ICU patients in the four countries considered, reducing infection rates and overall LOS, and resulting in a lower total cost per patient. Overall costs for patients receiving PN regimens containing omega-3 fatty acids were between €14 144 to €19 825 per ICU patient and €5484 to €14 232 per non-ICU patient, translating into savings of between €3972 and €4897 per ICU patient and savings of between €561 and €1762 per non-ICU patient. Treatment costs were completely offset by the reduction in hospital stay costs and antibiotic costs. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS These results suggest that the supplementation of PN regimens with omega-3 fatty acids would be cost effective in Italian, French, German and UK hospitals.
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Affiliation(s)
| | - Mario Eandi
- Pharmacology, Università degli Studi di Torino, Via Pietro Giuria 13, I-10100 Torino, Italy.
| | | | - Konstantin Mayer
- Lung Transplant Program, Internal Medicine, Pulmonary Medicine, Intensive Care Medicine, Sleep Medicine, Department of Internal Medicine, Justus-Liebig University Giessen, Klinikstrasse 36, D-35392 Giessen, Germany.
| | - Maurizio Muscaritoli
- Internal Medicine, Università La Sapienza, Via del Policlinico 155, I-00161 Rome, Italy.
| | - Axel R Heller
- Clinic for Anaesthesiology and Intensive Therapy, University Dresden, Fetscherstraße 74, D-01307 Dresden, Germany.
| | - Eva Fries-Schaffner
- Fresenius Kabi Deutschland GmbH, Rathausplatz 12, D-61348 Bad Homburg, Germany.
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Rössel T, Kersting S, Heller AR, Koch T. Combination of high-resolution ultrasound-guided perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block for carotid surgery. Ultrasound Med Biol 2013; 39:981-986. [PMID: 23499343 DOI: 10.1016/j.ultrasmedbio.2013.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/10/2012] [Accepted: 01/09/2013] [Indexed: 06/01/2023]
Abstract
All previously documented regional anesthesia procedures for carotid artery surgery routinely require additional local infiltration or systemic supplementation with opioids to achieve satisfactory analgesia because of the complex innervation of the surgical site. Here, we report a reliable ultrasound-guided anesthesia method for carotid artery surgery. High-resolution ultrasound-guided regional anesthesia using a 12.5-MHz linear ultrasound transducer was performed in 34 patients undergoing carotid endarterectomy. Anesthesia consisted of perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block. The internal carotid artery and the nerves of the superficial cervical plexus were identified, and a needle was placed dorsal to the internal carotid artery and directed cranially to the carotid bifurcation under ultrasound visualization. After careful aspiration, local anesthetic was spread around the internal carotid artery and the carotid bifurcation. In the second step, local anesthetic was injected below the sternocleidomastoid muscle along the previously identified nerves of the intermediate cervical plexus. The necessity for intra-operative supplementation and the conversion rate to general anesthesia were recorded. Ultrasonic visualization of the region of interest was possible in all cases. Needle direction was successful in all cases. Three to five milliliters of 0.5% ropivacaine produced satisfactory spread around the carotid bifurcation. For intermediate cervical plexus block, 10 to 20 mL of 0.5% ropivacaine produced sufficient intra-operative analgesia. Conversion to general anesthesia because of an incomplete block was not necessary. Five cases required additional local infiltration with 1% prilocaine (2-6 mL) by the surgeon. Visualization with high-resolution ultrasound yields safe and accurate performance of the block. Because of the low rate of intra-operative supplementation, we conclude that the described ultrasound-guided perivascular anesthesia technique is effective for carotid artery surgery.
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Affiliation(s)
- Thomas Rössel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany.
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Rössel T, Heller AR, Müller M, Müller A, Kersting S. Management of intraoperative embolic stroke during carotid surgery under regional anesthesia. VASA 2013; 42:139-43. [PMID: 23485842 DOI: 10.1024/0301-1526/a000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas Rössel
- Department of Anesthesiology and Intensive Care Medicine, University of Dresden, Germany
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Heller AR. Aiming is not enough: you must hit. Minerva Anestesiol 2012; 78:1316-1318. [PMID: 23222998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Heller AR. It is not enough to aim; you must hit. Minerva Anestesiol 2012:R02128313. [PMID: 23044745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- A R Heller
- Clinic of Anesthesiology and Intensive Care Medicine, Medical Faculty Carl Gustav Carus, University of Technology, Dresden, Germany -
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Pradelli L, Mayer K, Muscaritoli M, Heller AR. n-3 fatty acid-enriched parenteral nutrition regimens in elective surgical and ICU patients: a meta-analysis. Crit Care 2012; 16:R184. [PMID: 23036226 PMCID: PMC3682286 DOI: 10.1186/cc11668] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 10/04/2012] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Previous studies and a meta-analysis in surgical patients indicate that supplementing parenteral nutrition regimens with n-3 polyunsaturated fatty acids (PUFAs), in particular eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), is associated with improved laboratory and clinical outcomes in the setting of hyper-inflammatory conditions. Refined or synthetic fish oils are commonly used as a source of EPA and DHA. The objective of the present meta-analysis was to evaluate n-3 PUFA-enriched parenteral nutrition regimens in elective surgical and intensive care unit (ICU) patients. METHODS Medline was searched for randomized controlled trials comparing n-3 PUFA-enriched lipid emulsions with standard non-enriched lipid emulsions (i.e. soybean oil, MCT/LCT or olive/soybean oil emulsions) in surgical and ICU patients receiving parenteral nutrition. Extracted data were pooled by means of both random and fixed effects models, and subgroup analyses were carried forward to compare findings in ICU versus non-ICU patients. RESULTS A total of 23 studies (n = 1502 patients: n = 762 admitted to the ICU) were included. No statistically significant difference in mortality rate was found between patients receiving n-3 PUFA-enriched lipid emulsions and those receiving standard lipid emulsions (RR = 0.89; 0.59, 1.33), possibly reflecting a relatively low underlying mortality risk. However, n-3 PUFA-enriched emulsions are associated with a statistically and clinically significant reduction in the infection rate (RR = 0.61; 0.45, 0.84) and the lengths of stay, both in the ICU (-1.92; -3.27, -0.58) and in hospital overall (-3.29; -5.13, -1.45). Other beneficial effects included reduced markers of inflammation, improved lung gas exchange, liver function, antioxidant status and fatty acid composition of plasma phospholipids, and a trend towards less impairment of kidney function. CONCLUSIONS These results confirm and extend previous findings, indicating that n-3 PUFAs-enriched parenteral nutrition regimens are safe and effective in reducing the infection rate and hospital/ICU stay in surgical and ICU patients.
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Huhle R, Burghardt M, Zaunseder S, Wessel N, Koch T, Malberg H, Heller AR. Effects of awareness and nociception on heart rate variability during general anaesthesia. Physiol Meas 2012; 33:207-17. [PMID: 22260880 DOI: 10.1088/0967-3334/33/2/207] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
During anaesthesia awareness and nociception are serious complications that may further lead to haemodynamic instability. Specific monitoring of depth of hypnosis and depth of analgesia based on heart rate variability (HRV) analysis is eligible to improve patient safety and reduce efforts in post-operative care. Consequently, in this analysis we assess the applicability of HRV parameters during surgical interventions with standardized intravenous propofol-remifentanil-anaesthesia. Peri-operative electrocardiograms were recorded from cardiovascular stable patients (ASA Score I/II, N = 32, age: 36.4 ± 11.23 a, BMI: 25.2 ± 3.16) scheduled for trauma and dentofacial surgery. HRV time- and frequency-domain parameters, measures of complexity and nonlinear dynamics were compared by analysing longitudinally distributed 300 s intervals preceding/following induction of anaesthesia (BL-I1), intubation (I1-I2) and extubation (E1-E2). Mean value (meanNN) and standard deviation (sdNN) of the heart rate are influenced in BL-I1 (p < 0.001), I1-I2 (p < 0.05) and E1-E2 (p < 0.001). The number of forbidden words of symbolic dynamics changes significantly for BL-I1 (p < 0.001) and not for I1-I2 and E1-E2 (p > 0.05). Probability of low-variability POLVAR10 is significantly altered in all comparisons (BL-I1: Δ = 0.032, p < 0.01, I1-I2: Δ = 0.12, p < 0.05, E1-E2: Δ = 0.169, p < 0.01) but especially during nociception. While standard time-domain parameters lacked selectivity, parameters of symbolic dynamics appear to be specifically influenced by changes in depth of hypnosis and nociception, respectively. However, the lack of steady-state ventilation/breathing in this study needs to be considered in future research. To be used for clinical anaesthesia monitoring our results have to be prospectively validated in clinical studies.
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Affiliation(s)
- R Huhle
- Institute of Biomedical Engineering, Dresden Technical University, Dresden, Germany.
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Pradelli L, Mayer K, Muscaritoli M, Heller AR. Correction: n-3 fatty acid-enriched parenteral nutrition regimens in elective surgical and ICU patients: a meta-analysis. Crit Care 2012. [PMCID: PMC4057023 DOI: 10.1186/cc11909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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