Der Herzkathetertisch ist nicht der OP-Tisch

Background

Patients undergoing cardiac surgery need extensive and invasive monitoring, which needs to be individually adapted for each patient and requires a diligent risk-benefit analysis. The use of a pulmonary artery catheter (PAC) seems to be justifiable in certain cases; therefore, the preoperative diagnosis of pulmonary hypertension represents an indication for perioperative monitoring with PAC in the S3 guidelines of the German Society for Anesthesiology and Intensive Care Medicine (DGAI). In many cases, however, this preoperative diagnosis cannot be confirmed intraoperatively.

Objective

We wanted to find out whether this is just an impression or whether there actually are significant differences between preoperative, intraoperative and postoperative pulmonary artery pressures.

Material and methods

After obtaining ethical approval, we retrospectively compared the pulmonary pressures of cardiac surgery patients with an elevated pulmonary pressure during preoperative right heart catheterization with those obtained intraoperatively and postoperatively by means of a PAC. All patients with a preoperatively documented pulmonary artery pressure of 40 mmHg or above and an intraoperative use of a PAC during a 4-year period were included. Exclusion criteria were intracardiac shunts, cardiogenic shock, emergency procedures, pulmonary hypertension of non-cardiac origin and a time span of more than 1 year between right heart catheterization and surgery. We included 90 patients.

Results

In the whole group and in the subgroups (according to diagnosis, time elapsed between heart catheterization and operation and pulmonary pressure), there were significant differences between preoperative and intraoperative pulmonary and systemic pressures. Systemic and pulmonary artery pressures were significantly higher during preoperative catheterization than intraoperatively. The systemic systolic pressure/systolic pulmonary pressure ratio, however, remained constant. The intraoperative and postoperative systemic and pulmonary artery pressures showed no significant differences. As a normal ejection fraction does not exclude heart failure with preserved ejection fraction and as we did not have any information on this condition, we did not group the patients according to the ejection fraction.

Conclusion

An elevated pulmonary pressure obtained preoperatively during right heart catheterization is not indicative of an elevated pulmonary pressure either intraoperatively or postoperatively. There are various explanations for the differences (e.g., different physiological and pathophysiological settings, such as sedation with potential hypercapnia versus anesthesia with vasodilation when measured; newly prescribed medication coming into effect between the right heart catheterization and surgery; intraoperative positioning). Even though the inherent risks of a PAC seem to be low, we recommend refraining from using a PAC in patients with a once documented elevated pulmonary pressure by default. As an alternative we suggest estimating the pulmonary pressure by transesophageal echocardiography (TEE) as an aid to decide whether the patient will benefit from the use of a PAC. Especially if it is not possible to identify tricuspid valve regurgitation for determining the peak gradient, it is helpful to check for additional signs of pulmonary hypertension. But we also have to bear in mind that in the postoperative period only a PAC can provide continuous measurement of pulmonary pressure.

     

Wenn A nicht mehr A ist: Schwierigkeiten und Fallstricke bei der Blutgruppenbestimmung

Correct blood group typing is a prerequisite for transfusion. In most cases blood group determination is without problems; however, in individual cases various factors can complicate blood group determination and sometimes lead to confusing findings. For a better understanding the clinician should have basic knowledge of blood typing. Blood group determination usually covers the AB0 blood groups, Rhesus and Kell systems; in addition, a direct Coombs test and an antibody screening test for the detection of irregular antibodies in the recipient are performed. Confusion of patients, blood samples, results or preparations can lead to severe consequences due to incompatible transfusion and must be prevented. In this context, bedside blood type testing before transfusion is of utmost importance. Problems in laboratory analysis as well as patient-related factors, such as the existence of irregular antibodies against red blood cells can complicate the immunohematology diagnostics. Certain medications, such as daratumumab, lead to a significantly increased complexity in laboratory analyses. Massive transfusions can lead to chimerism with more than one population of circulating red blood cells. Hematopoetic stem cell transplantation can also lead to a change in blood groups as well as chimerism. In addition, there are various other rare causes that can result in difficulties in blood group determination, such as rare blood groups or rare disease-associated phenomena. In the case of problems in blood group determination, early and close cooperation with transfusion medicine is essential for the clinician.     

Sonographischer Stenosegrad ist nicht gleich sonographischer Stenosegrad ist nicht gleich angiographischer Stenosegrad

Background and problems

Color-coded duplex sonography is a recognized method for the diagnostics and therapy planning of arteriosclerotic femoropopliteal lesions. The sonographically detected peak systolic velocity (PSV) or ratios of prestenotic and intrastenotic peak velocities for quantification of stenoses reported in the literature vary considerably.

Methods

The study is based on a critical review of available literature between 1990 and 2012 on stenosis grading of femoropopliteal stenoses considering hemodynamic properties.

Results

The ratio of intrastenotic and prestenotic PSV showed improved sensitivity and specificity (>?90?%) and better stenosis grading than the absolute PSV value. The measurement site of prestenotic PSV is important for an adequate stenosis grading with respect to collateral arterial branches (continuity law). In addition the plaque configuration determines the hemodynamic effectiveness of a stenosis (variation from 40-75 % reduction of cross-sectional area with 50 % reduction in diameter) and therefore the intrastenotic PSV.

Discussion and conclusions

The parameters for color-coded duplex sonographic quantification of high-grade femoropopliteal stenosis described in the literature show considerable variation because insufficient attention has been paid to the effect of systemic factors and the importance of collateral vessels for the intrastenotic PSV and the plaque configuration for the hemodynamic efficacy of stenoses. In conclusion the hemodynamic stenosis criteria correlate more closely with the clinical symptoms than the individual reductions in diameter (angiography).     

Standards bei der Behandlung von Frakturen und Instabilitäten der HWS zwischen C3 und C7

More than one-third of all fractures and discoligamentous instabilities of the lower cervical spine are associated with neurological deficits. One out of every two traumas in this region is associated with additional injuries. The majority of lesions (75%) need operative therapy because of resultant instabilities. The golden standard is spondylodesis of a small number of vertebrae by an anterior approach. The dorsal approach is indicated only for fractures and luxations that cannot be reduced. In patients with Bechterew's disease a dorsoventral approach with multisegmental instrumentation is recommended. This usually leads to good fracture healing allowing complete reintegration of the patients into their social and professional life.     

298. Bakterielle Infektion der Gallenblase ist Ursache, nicht Folge des Gallensteinleidens

Zusammenfassung Im Innern von Cholesteringallensteinen konnten-glucuronidase-bildende Bakterien nachgewiesen werden. Durch die-Glucuronidase wird Bilirubin-di-glucuronid dekonjugiert und Bilirubincalcium fällt aus der Galle aus. Es wird angenommen, daß das unlösliche Bilirubincalcium als Nucleus für die Abscheidung von Cholesterinkristallen aus der supergesätfgten Galle von Cholesteringallensteinträgem dient. Diel-glucuronidase-bildenden Bakterien können als Nucleationsfaktor in der Pathogenese der Cholesteringallensteine angesehen werden.     

Tempor?re Instrumentation bei Luxationen, Subluxationen und Frakturen der unteren HWS

Die ventrale interkorporelle Spondylodese und Instrumentation gilt als Standardverfahren in der Versorgung instabiler Verletzungen der HWS. Ziel der Untersuchung war die Erhebung der Behandlungsergebnisse bei tempor?rer Stabilisation verletzter Bewegungssegmente der HWS. In der Zeit von 1990–1998 wurden an der Universit?t Ulm wegen Verletzungen der Halswirbels?ule insgesamt 155 Patienten operativ versorgt. Bei 22 Patienten erfolgte eine überbrückende Instrumentation des Bewegungssegmentes ohne Fusion, eine Implantatentfernung konnte inzwischen bei 12 Patienten vorgenommen werden.     

Aktuelle Entwicklungen in der Behandlung der Wirbelsäulenverletzungen (ohne HWS und RMV)

Trauma und Berufskrankheit -     

92. Was ist in der Krankenhaushygiene praktikabel und was ist reine Theorie?

ZusammenfaBung Die Krankenhaushygiene will Gefährdungen der Patienten besonders durch Infektionen verhindern und damit den Kliniker unterstützen. Ihre MaBnahmen sind stets dort praktikabel, wo sie die klinischen Belange berücksichtigt. Sie bleiben Theorie, wo zwar klinisch machbare, aber unbequeme Verhaltensänderungen verlangt werden. Personalforderungen scheitern z. T. noch am fehlenden Fachpersonal (Hygieniker, Hygieneschwester). Kostenintensive BaumaBnahmen haben optimales Verhalten des Personals zur VorauBetzung.     

Spätkomplikationen nach Schrittmacherimplantation ist nicht eingegangen

Ohne Zusammenfassung     

MRT in der Unfallchirurgie

The range of indications for magnetic resonance imaging (MRI), a diagnostic imaging technique that does not use ionizing radiation, in trauma surgery is wide and covers almost all problems encountered in trauma surgery. When there are any contraindications the radiologist should explain these and decide whether an MRI examination can be carried out nonetheless. In this paper findings typically encountered in trauma surgery are discussed. Within the discussion of fresh trauma, for instance, detailed information on what can be learned from MRI when there are bony and soft tissue injuries is given. Its use in subacute “chronic” trauma, to examine later findings following trauma, and in the case of inflammatory alterations is also presented. This procedure can also be used for differential diagnosis when clinical findings and symptoms are equivocal. It is also indicated when it is difficult to differentiate between late consequences of trauma and accident-dependent changes. Finally, specific MR techniques are discussed in detail.     

Sinnvolle und nicht sinnvolle Hygienema?nahmen in der Urologie

Zusammenfassung Katheterassoziierte Harnwegsinfektionen als häufigste nosokomiale Infektion und die postoperativen Wundinfektionen als zweithäufigste im Krankenhaus erworbene Infektion spielen in der Urologie als nosokomiale Infektionen die wichtigste Rolle. In dieser Übersicht sollen zum einen die Standardhygienemaßnahmen erläutert werden, der Schwerpunkt liegt jedoch auf den sinnvollen und nicht sinnvollen Maßnahmen zur Prävention katheterassoziierter Harnwegsinfektionen und der postoperativen Wundinfektionen. Die konsequente Umsetzung dieser Maßnahmen trägt dazu bei, die Infektionsrate zu minimieren und einen Qualitätsstandard zu etablieren, wobei die Surveillance nosokomialer Infektionen ein wesentlicher Beitrag zur internen Qualitätssicherung ist. Abstract In urology, catheter-associated urinary tract infections are the most common, and postoperative wound infections the second most common nosocomial infections. This article gives an overview of standard hygiene measures, but focuses on proven and unproven hygiene measures for the prevention of catheter-associated urinary tract infections and postoperative wound infections. Consistent implementation of these measures contributes to minimizing infection rates and to establishing a quality standard, whereby surveillance of nosocomial infections contributes substantially to internal quality assurance.     

Bone bruise und MRT

Bony and soft tissue injuries require precise diagnosis by means of imaging techniques. The basic examination performed is projection radiography in two planes. If the findings yielded by this technique appear to bear out expectations raised by the history, the mechanism of injury and the clinical examination, no further imaging procedures need be carried out. CT may be helpful when decisions have to be made on any surgery to be performed. When there is a discrepancy in the findings (e.g. suggestive clinical findings and unremarkable roentgenogram) MR imaging should be performed to check for microfractures and/or bone bruising. The latter takes the form of intraosseous oedema or haematoma linked with a trauma, and it is important to differentiate it from microfractures or occult fractures. Both T1- and T2-weighted sequences are needed, as are STIR- and SPIR-oriented sequences; as far as possible, the images must be three dimensional and orthogonal. Detection of bone bruising does not generally mean that active surgical intervention is indicated, but it does help to classify the mechanism of injury and complement the objectivization of the findings; it is also a significant factor in selection of the conservative treatment approach to be adopted or for a medium-term expert assessment.     

Sinnvolle und nicht sinnvolle Hygienemaßnahmen in der Chirurgie

Despite high standards in theatre design, surgical skills and antibiotic prophylaxis, surgical site infections are still a major complication in modern surgery. After urinary tract infections and lower respiratory tract infections they account for 15.8% of all nosocomial infections in Germany [31]. Causes are multiple and only partially exogenous. The single most important (exogenous) risk factor is the technical skill of the surgeon. Not all surgical site infections are therefore preventable by infection control measures alone. Useful and useless infection control measures will be evaluated critically in the following review according to data in the literature.