[Implementation of fast-track measures in colorectal resections : A survey among members of the DGAI]. / Umsetzung anästhesiologischer Fast-Track-Maßnahmen bei kolorektalen Resektionen : Eine Umfrage unter Mitgliedern der DGAI.

PURPOSE: The fast-track (FT) concept is a multimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo a survey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists. METHODS: Using the SurveyMonkey® online survey tool, 28 questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures. RESULTS: While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is a divergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected. CONCLUSION: The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Parameters predicting COVID-19-induced myocardial injury and mortality.

Clinical manifestations of COVID-19 affect many organs, including the heart. Cardiovascular disease is a dominant comorbidity and prognostic factors predicting risk for critical courses are highly needed. Moreover, immunomechanisms underlying COVID-induced myocardial damage are poorly understood. OBJECTIVE: To elucidate prognostic markers to identify patients at risk. RESULTS: Only patients with pericardial effusion (PE) developed a severe disease course, and those who died could be identified by a high CD8/Treg/monocyte ratio. Ten out of 19 COVID-19 patients presented with PE, 7 (78%) of these had elevated APACHE-II mortality risk-score, requiring mechanical ventilation. At admission, PE patients showed signs of systemic and cardiac inflammation in NMR and impaired cardiac function as detected by transthoracic echocardiography (TTE), whereas parameters of myocardial injury e.g. high sensitive troponin-t (hs-TnT) were not yet increased. During the course of disease, hs-TnT rose in 8 of the PE-patients above 16 ng/l, 7 had to undergo ventilatory therapy and 4 of them died. FACS at admission showed in PE patients elevated frequencies of CD3+CD8+ T cells among all CD3+ T-cells, and lower frequencies of Tregs and CD14+HLA-DR+-monocytes. A high CD8/Treg/monocyte ratio predicted a severe disease course in PE patients, and was associated with high serum levels of antiviral cytokines. By contrast, patients without PE and PE patients with a low CD8/Treg/monocyte ratio neither had to be intubated, nor died. CONCLUSIONS: PE predicts cardiac injury in COVID-19 patients. Therefore, TTE should be performed at admission. Immunological parameters for dysfunctional antiviral immunity, such as the CD8/Treg/monocyte ratio used here, supports risk assessment by predicting poor prognosis.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study.

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18-48 [0-116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.

[Frailty as potential indicator of perioperative risk for older patients]. / "Frailty" als potenzieller Indikator des perioperativen Risikos alter Patienten.

BACKGROUND: Physical, cognitive and social frailty is increasingly being recognized as a prognostic factor in the perioperative treatment of older patients; however, the concept of frailty has not been introduced into clinical routine in anesthesia. OBJECTIVES: Definition of terms, presentation of tools for determining the degree of frailty and measures to improve the clinical outcome of patients at risk. Proposal of a pragmatic approach for the detection and treatment of high-risk patients in everyday clinical practice. MATERIAL AND METHODS: Evaluation of current reviews and original publications. Discussion and modification of established frailty assessment tools in context of the needs in perioperative medicine. RESULTS: The degree of frailty is associated with the postoperative outcome. Depending on the definition used, the term frailty refers to a degraded resilience in the physical, mental or social domain. Although there is still no universal definition of frailty, it is clear that frailty is directly correlated with survival and postoperative morbidity. Classical perioperative risk markers such as age or ASA classification do not reach such high predictive value. For the perioperative screening and evaluation of frail patients, an adapted version of the MAGIC assessment in combination with two signal questions is recommended. The extent of frailty in a patient can be improved by a sufficient diet, by physiotherapeutic exercises and by providing cognitive aids; however, scientific proof that preoperative improvement of the frailty status subsequently improves postoperative results is available for only a few specific clinical conditions. CONCLUSION: In contrast to commonly used perioperative risk classifications, frailty is a sensitive marker for the patient's biological age. Therefore, it appears more suitable for estimating the perioperative risk than chronological age or other conventional tools, such as the ASA classification and is therefore a prerequisite for patient centered treatment pathways.

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]. / AltersTraumaZentrum DGU®: Evaluation klinischer und ökonomischer Parameter : Eine Pilotstudie an einer deutschen Universitätsklinik.

BACKGROUND: Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. OBJECTIVE: The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). METHODS: A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). RESULTS: In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035). CONCLUSION: There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

[Delirium in intensive care patients : A multiprofessional challenge]. / Delir beim Intensivpatienten : Eine multiprofessionelle Herausforderung.

Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. Due to the close connection between delirium, agitation and pain, sedation and analgesia must be evaluated at least every 8 h analogous to delirium screening. According to current knowledge, a multifactorial and multiprofessional approach is favored in the prevention and treatment of delirium. Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.

Efficacy of perioperative dexmedetomidine on postoperative delirium: systematic review and meta-analysis with trial sequential analysis of randomised controlled trials.

BACKGROUND: The influence of dexmedetomidine on postoperative delirium (POD) in adult surgical patients remains controversial. We aimed to analyse whether dexmedetomidine use could decrease POD incidence in this population and its relation to timing of dexmedetomidine administration and patient age. METHODS: We used random-effects modelled meta-analysis, trial sequential analysis, and followed Cochrane methodology with Grading of Recommendations Assessment, Development, and Evaluation (GRADE). PubMed and Cochrane library were searched up to July 2017 for randomised controlled trials that analysed POD incidence of adult surgical patients (age ≥18 yr) after dexmedetomidine administration. RESULTS: Eighteen studies (comprising 3309 patients) were included. There was decreased risk of POD with dexmedetomidine use for the entire adult surgical population [odds ratio (OR) 0.35; 95% confidence interval (CI) 0.24-0.51)], with firm evidence from trial sequential analysis. Pre-specified subgroup analyses confirmed this result with firm evidence for cardiac and non-cardiac surgical patients, (OR 0.41; 95% CI 0.26-0.63) and (OR 0.33; 95% CI 0.18-0.59), respectively. We also found firm evidence for reduction of POD if dexmedetomidine is administered during the postoperative period (OR 0.30; 95% CI 0.21-0.44), in patients aged <65 yr (OR 0.19; 95% CI 0.10-0.36) or ≥65 yr (OR 0.44; 95% CI 0.30-0.65). Evidence for dexmedetomidine's influence on secondary outcomes (in-hospital mortality, intensive care unit and hospital length of stay, bradycardia, and hypotension) is thus far insufficient to draw conclusions. CONCLUSION: Dexmedetomidine can reduce POD incidence for adult cardiac and non-cardiac surgical patients. The optimal dose and timing of dexmedetomidine and influence on other outcomes or particular patient populations with risk factors warrants further studies. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42017072380.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology

The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.(AU)

Risks and prevention of surgical fires : A systematic review.

Surgically induced fire is a life-threatening hazard; this topic has received little attention, although only 3 factors, the so-called fire triad, are needed for surgical fires to occur: an oxidizer, fuel and an ignition source. This systematic review aims to determine the impact of each component and to delegate every staff member an area of responsibility, thus ensuring patient health through prevention or protection. The trial was registered in Prospero CRD42018082656. A database search of eligible, preferably evidence-based studies was conducted. The Robins-I tool for assessing the risk of bias revealed a moderate risk of bias. Due to insufficient data, the main findings of these studies could not be summarized through a quantitative synthesis; therefore, a qualitative synthesis is outlined. The results are summarized according to the roles of the fire triad and discussed. (1) Role of the oxidizer: oxygen is the key component of the triad. Safe oxygen delivery is important. An oxygen-enriched environment (ORE) is caused by draping and is preferably prevented by suctioning. Fuel characteristics are affected by varying oxygen concentrations. (2) Role of the ignition source: electrocauterization is the most common ignition source, followed by lasers. Less common ignition sources include fiberoptic cables and preparative solutions, petrol or acetone. (3) Role of the fuel: surgical drapes are one of the most common fuels for surgical fires followed by the patient's hair and skin. Skin preparation solutions are among the less common fuels. Many fire-resistant materials have been tested that do not remain fire resistant in ORE. It was concluded that the main problem is defining the real extent of this hazard. Exact numbers and exact condition protocols are needed; therefore, standardized registration of every fire and future studies with much evidence are needed. Immediate prevention consists of close attention to patient safety to prevent surgical fires from happening.

The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre, randomized clinical trial.

BACKGROUND: Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. METHODS: This was a phase II, multicentre, randomized, double-blind, parallel-group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr-old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon- or sevoflurane-based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). RESULTS: Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 -14.9]) or with sevoflurane (13.6% [95% CI: 7.8 -19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least-squares mean difference: -0.33 [95% CI: -0.60 to -0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. CONCLUSIONS: Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA-scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. CLINICAL TRIAL REGISTRATION: EudraCT 2009-017153-35; ClinicalTrials.gov NCT01199276.