Fehler und Gefahren in der Herzchirurgie

Ohne Zusammenfassung Vortragender:E. Derra.     

Nutzen und Vorteile eines computergesteuerten mikrobiologischen Diagnose- und Datenerfassungssystems für die Antibioticatherapie in der Chirurgie

Zusammenfassung Um den Wert des vorgestellten Diagnose- and Datenerfassungssystems für den Kliniker aufzuzeigen, werden epidemiologische Aspekte von drei wichtigen Infektionen untersucht: Harnwegsinfekten, Infektionen des Respirations traktes and Wundinfekten. Bei den ersten beiden Beispielen sind bezüglich der Keimverteilungen zwischen den einzelnen Patientengruppen and dem Gesamtkollektiv überwiegend signifikante Unterschiede nachweisbar. Das dritte Beispiel zeigt, daß auch innerhalb einer Abteilung beiStaphylococcus epidermidis je nach untersuchter Station ein unterschiedliches Resistenzverhalten auftritt. Das letzte Beispiel zeigt die Möglichkeit, das Resistenzverhalten verschiedener Keime in beliebigen Zeiträumen darzustellen and zu vergleichen. Ist eine computergestützte Diagnose bereits bei ihrer Erstellung im Datenspeicher erfaßt, können statistische Untersuchungen jederzeit binnen Stunden durchgeführt werden. Der Kliniker gewinnt, gestützt durch solche sich auf seine Abteilung oder sogar Station beziehende Daten, an Sicherheit bei der Auswahl einer kalkulierten Therapie. Daneben kann durch den bis zu 24 h betragenden Zeitgewinn bei der Resistenztestung eine gezielte Therapie deutlich früher begonnen werden. Zusammengefaßt kann ein computergestütztes Diagnose- and Datenerfassungssystem durch schneller verfügbare and genauere epidemiologische Daten den Kliniker bei der Auswahl and Kontrolle der Antibioticatherapie erheblich unterstützen.

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Benefit and advantage of a computer-assisted microbiological diagnosis and database system for antibiotic therapy in surgery

Summary To demonstrate the value of a computer assisted microbiological diagnosis and database system for clinical use, epidemiological aspects of three important infections were investigated: urinary tract, respiratory tract and wound infections. The first two examples presented revealed significant differences in incidence of pathogens between a single patient group and the overall statistic. The third example demonstrates that even within a department susceptibility patterns ofstaphylococcus epidermidis were changing in dependence of the ward investigated. In the last example the evaluation of susceptibility testing revealed changing patterns of some pathogens during the observation periods. By means of a computer assisted diagnosis and database on file at the moment of diagnosis thus allowing statistical evaluations at every time within a few hours. The clinician provided with actual data concerning his ward or department may administer an empiric therapy according to the real situation. Besides this, automated susceptibility testing may shorten the time required for diagnosis up to 24 h, thus further contributing to a more rational antimicrobial therapy. In conclusion computer assisted diagnosis and automated instruments support the clinician by means of actual epidemiological data and rapid reporting in choosing and controlling antimicrobial therapy.

     

Grenzen und Herausforderungen der Triage in der Notfall- und Rettungsmedizin

Notfall + Rettungsmedizin -     

Qualität und Nutzen der Heilverfahren

Trauma und Berufskrankheit - Das bundesdeutsche Gesundheitssystem nimmt im internationalen Vergleich – mit einer flächendeckenden Versorgung auf allen Stufen unabhängig von...     

148. Mezlocillin und Oxacillin als Infektionsprophylaxe in der Herzchirurgie

Langenbeck's Archives of Surgery - Bei 22 konsekutiven am Herzen operierten Patienten wurden 3 g Optocillin bei Narkoseeinleitung infundiert and in defmierten Zeitabständen Serumproben...     

Nachwuchssicherung in der Herzchirurgie

Junior physicians are becoming less interested in surgical disciplines and the corresponding further education. Cardiac surgery is also still considered to be a predominantly male domain despite the increasing proportion of female physicians in total. Junior physicians and students who were born after 1982 belong to generation Y and are characterized by a high degree of self-confidence and a rejection of hierarchies. Specialty competence is decisive. This current generation is motivated by an optimal education. This article discusses the influence of income and workload, lifestyle, duration of further education and career prospects, prestige, mentors and prime examples, practical experience and teaching programs as factors in decision making for cardiac surgery further training. Finally, two examples of successful recruitment are presented.     

Hypothermie in der Herzchirurgie

Since the beginning of the era of cardiac surgery hypothermia remains a mainstay in perioperative management. This role is increasingly being questioned because of many disadvantages and the lack of evidence of advantages. Using modern techniques of perfusion and myocardial protection as well as improved surgical techniques the results with normothermia seem to be comparable. The importance of hypothermia in present day cardiac surgery is discussed with respect to myocardial and cerebral protection.     

Frauen in der Herzchirurgie

The present article outlines the current proportion of women in cardiac surgery in Germany in different positions ranging from medical school to chief of department. The special features of the cardiac surgeon’s profession are reviewed from the female author’s personal point of view.     

Gerinnungsmanagement in der Herzchirurgie

Background

Demographic changes and medical progress have resulted in a panoply of complex cardiovascular treatment modalities. Dealing with dual platelet aggregation inhibition (PI) as well as blood and blood product management is particularly challenging.

Aim

The current strategies are evaluated based on currently existing evidence from which practical clinical treatment modalities are derived.

Material and methods

A search was made in PubMed for publications in the last 10 years regarding dual PI, point of care coagulation management (POCT), intraoperative and postoperative management, blood and blood products, secondary prophylaxis, implantation of left ventricular assist devices (LVAD) and extracorporeal membrane oxygenation (ECMO) support. The level of evidence concerning current therapeutic recommendations was verified.

Results

Dual PI has clear benefits but also results in perioperative challenges. The quantity and quality of PI can be verified by POCT tools in order to derive individualized therapeutic strategies. A generally acknowledged recommendation for the intraoperative treatment of heparin-induced thrombocytopenia type II (HIT II) does not yet exist. Some technical innovations in extracorporeal circulation have gained widespread clinical use. Phenprocoumon remains indispensable after heart valve replacement. In cases of a necessary interruption established substitution protocols exist. Secondary prophylaxis after coronary artery bypass graft (CABG) is mandatory. For long-term anticoagulation therapy of LVADs promising approaches concerning equipoise between hemorrhagic and thromboembolic risks are ongoing.

Conclusion

As cardiac surgeons are still mainly responsible for treatment, good knowledge regarding the complex and frequently changing issue of coagulation management remains mandatory; however, in view of the enormous diversity, keeping pace with new developments is a challenge.     

Simultane Eingriffe der offenen Herzchirurgie und Ersatz des Truncus brachiocephalicus

Objective

We investigated the feasibility of open heart surgery with combined central vascular surgery and present our results from over 9 years.

Patients and Methods

Between August 94 and June 2003, nine patients underwent open heart surgery and central vascular surgery, i.e. replacement of the brachiocephalic trunk. Eight patients received coronary artery bypass grafting and one patient aortic valve replacement. For vascular surgery, a replacement of the brachiocephalic trunk using a Dacron-prosthesis as end-to-end anastomosis or as bifurcation-prosthesis was performed.

Results

The immediate postoperative survival was 100%. The duration of the operation had a median of 318 min (range: 294–345), perfusion time 67 min (range: 62–146), myocardial ischemic time 27 min (range: 11–83).

Conclusion

The immediate perioperative course indicates no significantly increased complication rate, although the durations of the operation and anesthesia were prolonged. We conclude that concomitant open-heart surgery with central vascular surgery can be performed with low risk and should take preference over surgical therapy in different settings.     

Erfahrungen zu Kosten und Nutzen in der Wirbelsäulenchirurgie

In the last 2 years, the use of navigation systems has become very widespread, especially in spinal surgery. Fluoroscopy- or CT-assisted navigation is possible. With the CT-assisted technique both surface and CT-fluoro-matching are possible. The instruments are calibrated with the aid of passive optical markers and with reference to the patient data. The intervention can be planned preoperatively with accurate positioning of the screws. A particular advantage of navigation when the patient is in prone position is that dorsoventral navigation is possible at the same time. Dangers of navigation must be seen in the fact that a virtual world is presented that is not sure to correspond to reality (e.g. if the reference clamps slip). For this reason an experienced surgeon is needed even when a navigation system is used. Navigation is very useful for research and teaching purposes.     

Blutungsprobleme in der offenen Herzchirurgie

Across centers, transfusion can vary eightfold for the same mediastinal drainage after adult cardiac operations. Excessive blood drainage resulting in increased transfusions occurs in 29% of patients. Various strategies have been proposed to decrease bleeding and allogenic transfusion requirements in the perioperative period of heart surgery. Blood conservation methods were reviewed critically. Avoidance of preoperative anemia, tolerance of low hemoglobin concentrations, the use of autologous blood, and adherence to a strict transfusion protocol will reduce the use of allogenic transfusions. Perioperatively, maintenance of normothermia contributes to improved hemostasis.