[Implementation of a new emergency room protocol at a University Medical Center in Germany: basis for improved flow of information, adequate quality management and scientific assessment]. / Implementierung eines neuen Schockraumprotokolls an einem Universitätsklinikum in Deutschland: Grundlage für einen verbesserten Informationsfluss, adäquates Qualitätsmanagement und wissenschaftliche Auswertungen.

BACKGROUND: After analyzing the existing documentation protocol for the emergency room (ER), the department of anesthesiology of the Medical University of Göttingen (UMG) developed a new department-specific ER protocol. AIM: The objective was to improve the flow of patient information from the preclinical situation through the emergency room to the early inpatient period. With this in mind a new emergency protocol was developed that encompasses the very heterogeneic patient collective in the ER as well as forming a basis for quality management and scientific investigation, taking user friendliness and efficiency into consideration. MATERIAL AND METHODS: A strategical development of a new emergency room protocol is represented, which was realized using a self-developed 8-step approach. Technical support and realization was carried out using the Scribus 1.4.2 open source desktop and GIMP 2.8.4 GNU image manipulation graphic programs. RESULTS: The new emergency room protocol was developed based on scientific knowledge and defined targets. The following 13 sections represent the contents of the new protocol: general characteristics, emergency event, initial findings and interventions, vital parameters, injury pattern, vascular access, hemodynamics, hemogram/blood gas analysis (BGA), coagulopathy, diagnostics, emergency interventions, termination of ER treatment and final evaluation. CONCLUSION: The structured and elaborated documentation was limited to the target of two sides and succeeds in incorporating trauma patients as well as non-trauma patients in the ER.

[Pre-existing pain as comorbidity in postoperative acute pain service]. / Vorbestehender Schmerz als Komorbidität im postoperativen Akutschmerzdienst.

BACKGROUND: Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context. MATERIAL AND METHODS: This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (>12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared. RESULTS: A total of 128 patients (38% female, 62% male, aged 15-88 years old, mean age 59.8 ± 14.4 years) were seen by the APS on 633 occasions. Of these patients 91% had been admitted to hospital for surgery (66% for tumor surgery, 8% joint replacement, 9% other joint surgery and 16% other interventions), 50% had acute postoperative pain without pre-existing pain, 50% had had pre-existing pain for at least 12 weeks, 31% had chronic non-cancer pain and 19% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services. CONCLUSION: Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.

[Sepsis in adult patients - definitions, epidemiology and economic aspects]. / Definition, Epidemiologie und ökonomische Aspekte der Sepsis bei Erwachsenen.

Worldwide, sepsis is one of the leading causes of morbidity and mortality. In Germany about 79,000 (116/100,000) suffer from sepsis, and the incidence of severe sepsis and septic shock is about 75,000 cases per year. Patients are at high risk for irreversible organ failure and a lethal course. About 60,000 die from sepsis annually, and survivors have a reduced quality of life. It is presumed that demographic changes will lead to an increased incidence and overall mortality in the future. Additionally sepsis imposes a considerable economic burden to the society. Early and comprehensive treatment significantly improves outcome. An increased knowledge and awareness about the epidemiology, definitions and therapy of sepsis might contribute to the improved outcome. This review aims to present information on current definitions, epidemiology and the economic burden of sepsis.

Utility of cystatin C for assessment of renal function after cardiac surgery.

BACKGROUND: Though acute renal failure among cardiac surgery patients is associated with increased mortality, diagnosis of renal failure is often delayed due to the late detectability of laboratory markers for kidney failure. Recently, a number of clinical studies have shown that glomerular filtration rate (GFR) can be estimated by measuring the serum concentration of cystatin C (CysC). However, comparisons between the diagnostic effectiveness of CysC and serum creatinine have been inconsistent. The present study compares the diagnostic effectiveness of both serum markers in cardiac surgery patients. METHODS: In 50 cardiac surgery patients, GFR was quantified by measuring creatinine clearance and estimated from serum concentrations of both creatinine and CysC. The sensitivity and specificity of serum creatinine and CysC for detection of reduced GFR values were compared as well as correlation between estimated GFR values and creatinine clearance. RESULTS: GFR values <60 ml/min/1.73 m(2) were detected with equal effectiveness using creatinine or CysC, whereas for the detection of GFR <90 ml/min/1.73 m(2) the area under the curve of serum creatinine was significantly higher. Correlation between estimated GFR values and creatinine clearance was higher when creatinine-based formulae were used. CONCLUSION: In patients after cardiac surgery, CysC is not superior to serum creatinine for assessment of GFR.

[Perioperative thermal management]. / Perioperatives Wärmemanagement.

Perioperative hypothermia can influence clinical outcome negatively. It triples the incidence of adverse myocardial outcomes, significantly increases perioperative blood loss, significantly augments allogenic transfusion requirements, and increases the incidence of surgical wound infections. The major causes are redistribution of heat from the core of the body to the peripheral tissues and a negative heat balance. Adequate thermal management includes preoperative and intraoperative measures. Preoperative measures, e.g., prewarming, enhance heat content of the peripheral tissues, thereby reducing redistribution of heat from the core to the peripheral tissues after induction of anesthesia. Intraoperative measures are active skin surface warming of a large body surface area with conductive or convective warming systems. Intravenous fluids should be warmed when large volumes of more than 500-1000 ml/h are required. The body surfaces that cannot be actively warmed should be insulated. Airway humidification and conductive warming of the back are less efficient.

Computer tomographic assessment of perfluorocarbon and gas distribution during partial liquid ventilation for acute respiratory failure.

The average in vivo chest computed tomographic (CT) attenuation number (air = -1,000, soft tissue = 0, perflubron = +2,300 Hounsfield units [HU]) of 10 ventrodorsal-oriented lung segments was calculated to assess the distribution of gas and perflubron in 14 oleic acid lung-injured adult sheep during partial liquid ventilation (PLV, n = 7) or gas ventilation (GV, n = 7). Partial liquid ventilation was associated with a significant decrease in shunt fraction (PLV = 40 +/- 12%, GV = 76 +/- 12%, p = 0.004). Computed tomographic attenuation data during expiration (HUexp) demonstrated minimal gas aeration in GV animals in the dependent (segments 6-10) lung zones (HUexp = -562 +/- 108 for segments 1-5, HUexp = -165 +/- 104 for segments 6-10, p = 0.015). During PLV, perflubron was predominantly distributed to the dependent lung regions (HUexp = 579 +/- 338 for segments 1-5, HUexp = 790 +/- 149 for segments 6-10, p = 0.04). The ratio of the inspiratory to expiratory HU (HUinsp/exp) was greater in dependent than nondependent regions (mean HUinsp/exp segments 1-5 = 0.56, segments 6-10 = 0.81, p = 0.01), indicating that during inspiration relatively more gas than perflubron was distributed to the nondependent lung regions. We conclude that during PLV in this lung injury model, (1) gas exchange is improved when compared with gas ventilation, (2) perflubron is distributed predominantly to the dependent regions of the lung, and (3) although gas is distributed throughout the lung with each inspiration, more gas than perflubron goes to the nondependent lung regions.