Postoperative cognitive dysfunction (POCD) is being recognized as a complication contributing to perioperative morbidity and mortality of the elderly. We hypothesized that the use of the ...shorter-acting volatile anaesthetic desflurane would be associated with less incidence of POCD when compared with sevoflurane.
Approved by the local ethical committee, 80 patients (aged 65–75 yr) were enrolled in this randomized, double-blinded study. Patients were allocated to either the desflurane (n=40) or the sevoflurane (n=40) group. The primary outcome was the cognitive Test for Attentional Performance with its subtests Alertness, Divided Attention, Visual Scanning, Working Memory, and Reaction Change. In addition, Paper–Pencil Tests Well-being Test BF-S, Recall of Digit Span (DST), Digit-Symbol-Substitution Test, Trail Making Tests A and B, and Spielberg State-Trait Anxiety Inventory were measured. After baseline assessment 12–24 h before operation, patients were followed up 6–8 and 66–72 h after operation. Among other outcome parameters, emergence times from anaesthesia and modified Aldrete scores were recorded.
There was no difference in the incidence of POCD. However, according to the Paper–Pencil Tests, significant improvements for the desflurane group could be detected (Well-being Test at 6–8 h, DST at 6–8 h, and Trail Making Test at 66–72 h). Emergence was significantly faster in the desflurane group for ‘time to open eyes’ and ‘time to extubation’.
The total incidence of POCD showed no differences between the desflurane and the sevoflurane groups. However, the tests Well-being scale, DST, and Trail Making Test, emergence times, and patients’ satisfaction were in favour of desflurane.
Background
External chest compressions (ECC) are essential components of resuscitation and are usually performed without any adjuncts in professional healthcare. Even for healthcare professionals ...during in-hospital and out-of-hospital resuscitation poor performance in ECC has been reported in recent years. Although several stand-alone devices have been developed none has been implemented as a standard in patient care. The aim of this study was to examine if the use of a mechanical device providing visual feedback and audible assistance during ECC improves performance of healthcare professionals following minimal and simplified instructions.
Methods
In a prospective, randomized cross-over study 81 healthcare professionals performed ECC for 3 min (in the assumed setting of a secured airway) twice on a manikin (Skillreporter ResusciAnne®, with PC-Skillreporting System Version 1.3.0, Laerdal, Stavanger, Norway) in a mock cardiac arrest scenario. Group 1 (n=40) performed ECC with the device first followed by classic ECC and group 2 (n=41) in the opposite order. Minimal instructions were standardized and provided by video instruction (1 min 38 s). Endpoints were achievement of a mean compression rate between 90 and 110/min and a mean compression depth of 40–50 mm. In addition participants had to answer questionnaires about demographic data, professional experience and recent recommendations for ECC as well as their impression of the device concerning the ease of use and their personal level of confidence. Data were analyzed for group-related and inter-group differences using SAS (Version 9.1.3, SAS Institute, Cary, NC).
Results
A total of 81 healthcare professionals regularly involved in resuscitation attempts in pre-hospital or in-hospital settings took part in the study with no differences between the groups: females 35.8% (n=52), emergency medical technicians 32.1% (n=26), anesthesia nurses 32.1% (n=26), physicians (anesthesiology) 45% (n=29). In group 1 33 out of 40 (82.5%; 99.7±4.82/min; 95% confidence interval 95% CI: 98.1–101.2/min) reached the correct range for compression rate and 29/40 (72.5%; 44.0±4.95 mm; 95% CI: 42.4–45.6 mm) the correct compression depth using the assisting device. Afterwards they conducted classic ECC without the device and deteriorated significantly: correct compression rate was achieved by 12/40 (30%, p≤0.0001; 110.6±11.0/min (95% CI: 107.1–114.1/min), while 25/40 (62.5%; 44.5±5.63 mm; 95% CI: 42.6–46.3 mm) met the correct compression depth. Group 2 performed poorer in ECC without assistance and 5/41 (12.2%; 104.5±21.35/min; 95% CI: 97.8–111.3/min) reached the correct rate whereas 21/41 (51.2%; 39.6±7.61 mm; 95% CI: 37.2–42.0 mm) compressed to the appropriate depth. Using the device there was a significant improvement in the second evaluation with 34/41 (82.9%, p≤0.0001; 101.7±4.68/min; 95% CI: 100.2–103.2/min) reaching the correct rate and 36/41 (87.8%, p≤0.0001; 43.9±4.16 mm; 95% CI: 42.6–45.2 mm) the correct depth.
Conclusions
The tested device is easy to use after instruction of less than 3 min and improves ECC performance of healthcare professionals in simulated cardiac arrest with respect to compression depth as well as compression rate.
Zusammenfassung
Telemedizin erhält in immer mehr Bereiche der Medizin Einzug und zeigt ein starkes Marktwachstum. In der Notfallmedizin sind Systeme, die eine Vernetzung zweier stationärer ...Einrichtungen ermöglichen (interklinische Systeme) von den Systemen zu unterscheiden, die eine Vernetzung mit einem mobilen Partner ermöglichen (z. B. Rettungswagen). Für die 12-Kanal-EKG-Übertragung an einen beratenden Kardiologen wurde gezeigt, dass therapierelevante Zeitintervalle verkürzt werden können. Eine strukturierte telemedizinische Vorabinformation beim Schlaganfall kann die Zeit bis zur Bildgebung verkürzen und die Lyserate erhöhen. Im interklinischen Bereich sind ebenfalls Telemedizinsysteme eingeführt worden, deren Nutzen beim akuten Schlaganfall mittlerweile wissenschaftlich belegt ist. Auch in Deutschland kann präklinische Telemedizin rechtssicher erfolgen, jedoch sind vielfältige Aufgaben zu bewältigen, bevor sie als Bestandteil der Regelversorgung im Notfall zur Anwendung kommen kann. Neben der technischen Weiterentwicklung ist der wissenschaftliche Nachweis zu erbringen, unter welchen Bedingungen durch Telemedizin die Versorgungsqualität und letztlich das Outcome verbessert werden können.
To investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements.
From 1 July 2007 to 28 February 2008, data from all paper-based ...protocols of a physician-run EMS in Aachen, Germany, were transferred to a SQL database (n=4815). Database queries were conducted after personal data had been anonymised. Documentation ratios of 11 individual parameters were analysed at two points in time (T1, scene; T2, arrival in emergency department). The calculability of the Mainz Emergency Evaluation Score (MEES, embracing seven vital parameters) was investigated. The calculability of the Revised Trauma Score (RTS) was also determined for all trauma patients (n=408). Fisher's exact test was used to compare differences in ratios at T1 versus T2.
The documentation ratios of vital parameters ranged from 99.33% (Glasgow Coma Scale, T1) to 40.31% (respiratory rate, T2). The calculability of the MEES was poor (all missions: 28.31%, T1; 22.40%, T2; p<0.001). In missions that required cardiopulmonary resuscitation (n=87), the MEES was calculable in 9.20% of patients at T1 and 29.89% at T2 (p<0.001). In trauma missions, the RTS was calculable in 37.26% at T1 and 27.70% at T2 (p=0.004).
Documentation of vital parameters is carried out incompletely, and documentation of respiratory rate is particularly poor, making calculation of accepted emergency scores infeasible for a significant fraction of a given test population. The suitability of paper-based documentation is therefore limited. Electronic documentation that includes real-time plausibility checks might improve data quality. Further research is warranted.
Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee ...on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances sometimes must be considered in patient treatment resulted in a separate chapter. This first part of a two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of life-threatening drowning, asthma, anaphylaxis, and poisoning. The second part will deal with electrolyte disorders, hypothermia, electrical emergencies, trauma, cardiac arrest during pregnancy, and cardiac surgery.
Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee ...on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances for cardiac arrest must be considered resulted in a separate chapter. This two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of electrolyte disorders, hyperthermia and hypothermia, cardiac arrest in pregnancy, trauma, electrical emergencies and cardiac surgery. Part 1 has already dealt with life-threatening drowning, asthma, anaphylaxis and poisoning.
Zusammenfassung
Hintergrund
Im Rettungsdienst sollte die Patientenversorgung evidenzbasiert erfolgen. In dieser Studie wurde die medikamentöse Ausstattung notarztbesetzter Rettungsmittel erfasst. Für ...ausgewählte „Tracer“-Diagnosen wurden die Medikamentenbestände analysiert und mit dem Bedarf nach Leitlinien verglichen.
Methode
Von Mai 2008 bis Januar 2009 wurden alle 148 Ärztlichen Leiter Rettungsdienst (ÄLRD), die bei der Bundesgeschäftsstelle des Bundesverbandes der Ärztlichen Leiter Rettungsdienst Deutschland e. V. registriert sind, angeschrieben und um Übersendung ihrer Medikamentenausstattungslisten gebeten. Die Auswertung erfolgte anonymisiert. Als Tracer-Diagnosen dienten „kardiopulmonale Reanimation (CPR)“, „akutes Koronarsyndrom (ACS)“, „Status generalisierter tonisch-klonischer Krampfanfall“, „schwerer Asthmaanfall“ bzw. „akute Exazerbation einer chronisch obstruktiven Lungenerkrankung (COPD)“, „Schmalkomplextachykardie“, „schweres Schädelhirntrauma (SHT)“ und „akute Herzinsuffizienz mit Zeichen der Hypoperfusion“. Die aktuellen Leitlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. dienten als Grundlage und wurden mit internationalen Leitlinien abgeglichen.
Ergebnisse
Die Rücklaufquote betrug 64,2%; 39 Stoffgruppen und 142 verschiedene Medikamente konnten ermittelt werden. Der Leitlinienabgleich ergab, dass mit einer Häufigkeit von etwa 30–80%, abhängig von der jeweiligen Tracer-Diagnose, keine medikamentöse Akuttherapie nach höchstem Evidenzgrad erfolgen kann.
Schlussfolgerung
Aufgrund aktueller Therapieempfehlungen sollte die Ausstattung mit Noradrenalin, Adenosin, Dobutamin, Natriumbikarbonat, Kalzium, Magnesium, Lorazepam zur i.v.-Applikation sowie mit Ipratropiumbromid und Salbutamol (beide als Fertiginhalat) verbessert werden. Für die Zukunft ist ein bundeseinheitlicher Mindeststandard nach evidenzbasierten Grundlagen anzustreben.
Zusammenfassung
Es bedarf neuer Konzepte, um bestehenden und zukünftigen Problemen im Rettungsdienst zu begegnen. Mangelndes Qualitätsmanagement bei steigendem Kostendruck und zunehmendem ...(Not-)Ärztemangel kann zu messbaren Defiziten in der Notfallversorgung führen. Zudem wird derzeit eine veraltete Informationstechnik eingesetzt. Das Notarztsystem muss einerseits eine Modernisierung und Qualitätssteigerung erfahren, andererseits sind deutlichere Nachweise der Leistungsfähigkeit vonnöten. Nur so kann eine hochwertige Patientenversorgung für die Zukunft gewährleistet werden. Vor diesem Hintergrund wurde die Projektidee Med-on-@ix in Aachen mit dem Ziel entwickelt, die Versorgungsqualität und die Einsatzeffizienz zu steigern. Hierzu wird ein umfassendes notfallmedizinisches Telemedizinsystem entwickelt, das Notärzten und Rettungsdienstpersonal eine zusätzliche Beratung durch ein Kompetenzzentrum bereitstellt. Die leitliniengerechte Behandlung soll dadurch unter direkter Qualitätskontrolle sichergestellt werden. Prospektive Studien am Simulator und im realen Einsatz evaluieren das System im Vergleich mit dem aktuellen Rettungssystem.
The emergency medical service (EMS) should work according to criteria of evidence-based medicine. In Germany the EMS of each state is under the control of at least one medical supervisor known as ...emergency medical directors (EMD) and most states have several different EMDs responsible for one or more provinces of the state. The German Medical Association advises these supervisors to specify the pharmacological resources in store for use in physician powered EMSs. This study examines the pharmacological resources in EMSs which is provided by the EMDs in Germany. Furthermore, a comparison of the inventory analysis of stored drugs was carried out with the requirements according to guidelines for selected tracer diagnoses.
In the period of May 2008 to January 2009 a total of 148 EMDs were contacted and asked to supply drug storage lists for emergency physician-staffed rescue vehicles in their respective jurisdiction. The addresses of all EMDs who could be identified by the federal office of the National Association of Emergency Medical Director, Germany were used over the period. The evaluation was conducted anonymously. The tracer diagnoses "cardiopulmonary resuscitation", "acute coronary syndrome", "status generalized tonic-clonic seizure," "severe asthma attack", "acute exacerbation of chronic obstructive pulmonary disease", "supraventricular tachycardia", "severe brain trauma" and "acute heart failure with signs of hypoperfusion" were selected. Current and established guidelines have been identified with the homepage of the Scientific Medical Societies in Germany and supported by the leading European and International guidelines.
The corresponding lists were returned by 95 different emergency service areas (response rate 64.2%). With a total of 39 groups of substances 142 different drugs could be identified, an average of 54±9.6 and median 55 (range 31-77). Listed are agents giving the provision in percent, for which the comparison with guidelines for tracer diagnoses could show deficits: sodium bicarbonate 75.8%, calcium 50.5%, magnesium 45.3%, noradrenaline 65.3%, adenosine 58.9%, dobutamine 57.9%, lorazepam iv 13.7%, salbutamol 41.1%, ipratropium bromide 13.7% (the last two as liquid preparations for inhalation). With a frequency of about 30-80%, depending on the respective tracer diagnosis, no medical emergency treatment according to the highest level of evidence is possible.
Due to recent treatment recommendations provision with sodium bicarbonate, calcium, magnesium, noradrenaline, adenosine, lorazepam iv, dobutamine and as well with ipratropium bromide and salbutamol (both as liquid preparations for inhalation) should be improved. For the future, a federal uniform minimum standard due to evidence-based principles is desirable.
There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS ...physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.
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