Patient Blood Management in der Geburtsvorbereitung,Geburtshilfe und postpartalen Phase

Die Anaesthesiologie - Die Implementierung eines Patient Blood Management (PBM) wird zunehmender Standard in der operativen Medizin. Seit einiger Zeit gilt das Interesse auch den vulnerablen...     

Development of a clinical guideline on medical rehabilitation of patients after lumbar disc surgery

In cooperation with the Federation of German Pension Insurance Institutes (VDR) and with the VfR Norderney e. V., the university of Witten/Herdecke has developed a clinical guideline on medical rehabilitation for patients after lumbar disc surgery. Methodically, development of this guideline was based on the following three steps: (1) consideration of recent scientific literature, (2) analyses of structures and processes employed in rehab clinics, using consultations with clinic managers, with occupational groups involved in rehabilitation and analysis of patient files, as well as (3) the consensus process. One central result was the statement of substantial paucity of research on evidence for many therapeutic interventions used in orthopaedic rehabilitation of patients after lumbar disc surgery. Analyses and investigations in rehabilitation clinics showed a wide range of therapeutic interventions, used to very different extents. Development of the guideline therefore took place on the basis of consensus-based processes. Using formal consensus techniques according to recommendations of the Association of the scientific medical societies in Germany (AWMF), the guideline presented was developed in cooperation with the occupational groups involved in the rehabilitation process. Its structure focuses on the therapeutic targets, and it includes a clinical algorithm illustrating the orthopaedic rehabilitation process in a simple and understandable manner. The guideline presented is based on recent knowledge and corresponds to stage S2 of development. A further implementation project will evaluate practicability and acceptance of this guideline.     

Impact of glucose in peritoneal dialysis: saint or sinner?

Peritoneal dialysis (PD) solutions using glucose as osmotic agent have been used for more than two decades as effective treatment for patients with end-stage renal disease. Although alternative osmotic agents such as amino acids and macromolecular solutions, including polypeptides and glucose polymers, are now available, glucose is still the most widely used osmotic agent in PD. It has been shown to be safe, effective, readily metabolized, and inexpensive. On the other hand, it is widely assumed that exposure of the peritoneal membrane to high glucose concentrations contributes to both structural and functional changes in the dialyzed peritoneal membrane. As in diabetes, glucose, either directly or indirectly through the generation of glucose degradation products or the formation of advanced glycation end products, may contribute to peritoneal membrane failure. Although efforts to reduce glucose toxicity have been made for years, only a few suggestions, such as dual-bag systems with bicarbonate as buffer system, have found broader acceptance. Recently, some interesting new approaches to the problem of glucose-related toxicity have been made, but further investigations will be necessary before they can be used clinically. This review will focus on adverse effects of glucose in PD solutions and summarize different aspects of glucotoxicity and potential therapeutic interventions.     

Quantification of metabolites in breast cancer patients with different clinical prognosis using HR MAS MR spectroscopy

Absolute quantitative measures of breast cancer tissue metabolites can increase our understanding of biological processes. Electronic REference To access In vivo Concentrations (ERETIC) was applied to high resolution magic angle spinning MR spectroscopy (HR MAS MRS) to quantify metabolites in intact breast cancer samples. The ERETIC signal was calibrated using solutions of creatine and TSP. The largest relative errors of the ERETIC method were 8.4%, compared to 4.4% for the HR MAS MRS method using TSP as a standard. The same MR experimental procedure was applied to intact tissue samples from breast cancer patients with clinically defined good (n = 13) and poor (n = 16) prognosis. All samples were examined by histopathology for relative content of different tissue types and proliferation index (MIB‐1) after MR analysis. The resulting spectra were analyzed by quantification of tissue metabolites (β‐glucose, lactate, glycine, myo‐inositol, taurine, glycerophosphocholine, phosphocholine, choline and creatine), by peak area ratios and by principal component analysis. We found a trend toward lower concentrations of glycine in patients with good prognosis (1.1 µmol/g) compared to patients with poor prognosis (1.9 µmol/g, p = 0.067). Tissue metabolite concentrations (except for β‐glucose) were also found to correlate to the fraction of tumor, connective, fat or glandular tissue by Pearson correlation analysis. Tissue concentrations of β‐glucose correlated to proliferation index (MIB‐1) with a negative correlation factor (?0.45, p = 0.015), consistent with increased energy demand in proliferating tumor cells. By analyzing several metabolites simultaneously, either in ratios or by metabolic profiles analyzed by PCA, we found that tissue metabolites correlate to patients' prognoses and health status five years after surgery. This study shows that the diagnostic and prognostic potential in MR metabolite analysis of breast cancer tissue is greater when combining multiple metabolites (MR Metabolomics). Copyright © 2010 John Wiley & Sons, Ltd.     

Granulocyte-colony stimulating factor in the prevention of postoperative infectious complications and sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4)¶ Protocol for a controlled clinical trial developed by consensus of an international study group¶ Part two: design of the study

GENERAL DESIGN: Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). This part describes the design of the randomised, placebo controlled, double-blinded, single-centre study performed at an university hospital (n = 40 patients for each group). OBJECTIVE: The trial design includes the following elements for a prototype protocol: * The study population is restricted to patients with colorectal cancer, including a left sided resection and an increased perioperative risk (ASA 3 and 4). * Patients are allocated by random to the control or treatment group. * The double blinding strategy of the trial is assessed by psychometric indices. * An endpoint construct with quality of life (EORTC QLQ-C30) and a recovery index (modified Mc Peek index) are used as primary endpoints. Qualitative analysis of clinical relevance of the endpoints is performed by both patients and doctors. * Statistical analysis uses an area under the curve (AUC) model for improvement of quality of life on leaving hospital and two and six months after operation. A confirmatory statistical model with quality of life as the first primary endpoint in the hierarchic test procedure is used. Expectations of patients and surgeons and the negative affect are analysed by social psychological scales. CONCLUSION: This study design differs from other trials on preoperative prophylaxis and postoperative recovery, and has been developed to try a new concept and avoid previous failures.     

In-hospital evaluation of contamination of duodenoscopes: a quantitative assessment of the effect of drying.

A prospective, quantitative assessment was undertaken of the effect of drying on the bacterial load in duodenoscopes that had been used for endoscopic retrograde cholangiopancreatography procedures. The endoscopes were washed and disinfected using an automatic washer and samples were taken through the suction channel at 2, 24 and 48 h post-disinfection. Twenty-one of the 42 duodenoscopes tested were contaminated. The ratio of Gram-negative bacilli to Gram-positive cocci increased from 70:1 at 2 h up to 4000:1 at 48 h for those duodenoscopes that were contaminated. Pseudomonas species (6 of 12 contaminated endoscopes) and Acinetobacter species (7 of 21 contaminated endoscopes) were the most common isolates. There was visible moisture remaining in the suction channel despite the use of the complete recommended automatic washer cycle. Bacterial concentrations reached as high as 1 x 10(7) colony forming units (cfu) ml-1. An additional 10 min of drying using either an 'in house' air line or the manual machine dry prevented bacterial overgrowth of all 19 endoscopes tested 48 h post-disinfection. If the additional 10 min of drying was used, then no alcohol rinse was required. Although no infections related to use of contaminated endoscopes were reported, it was apparent that Gram-negative bacilli were multiplying to unacceptably high concentrations and that this could be prevented by an additional 10 min of drying. The additional drying was only required at the end of the endoscopy list and not between patients.     

Ultrasonic diagnosis in suspected acute appendicitis: probable or certain indications for surgery?]

The diagnostic accuracy and the clinical impact of routine ultrasonography performed by 4 surgeons, were prospectively studied in 366 unselected patients admitted for suspected acute appendicitis. Clinical and sonographic findings on admission were correlated with laparotomy findings, pathological outcome and clinical as well as follow-up data. The overall sensitivity, specificity and accuracy of the clinical diagnosis of acute appendicitis were 55.3%, 94.6% and 84.2% respectively (positive predictive value (PPV) 75.8%, negative predictive value (NPV) 87.3%). Ultrasound enabled visualization of the disease in 67 of 85 (prevalence 23.3%) patients with a histologically confirmed acute appendicitis; false positive results were recorded in 7 cases (sensitivity 78.8%, specificity 97.5%, accuracy 93.1%, PPV 90.5%, NPV 93.8%). Ultrasound was particularly useful in patients presenting with equivocal or highly unsuspective signs of acute appendicitis: of 38 patients with an acute appendicitis in this group ultrasonography enabled to make the diagnosis in 26. The combined approach of clinical evaluation and routine ultrasonography markedly improved the diagnostic accuracy (sensitivity 85.9%, specificity 96.4%, accuracy 94%) and substantially reduced the negative laparotomy rate (7.9%) in patients with suspected acute appendicitis. It is concluded, that ultrasonographic evaluation of the patient with suspected acute appendicitis performed by surgeons is of great assistance in surgical practice.