Thoraxkompressionsqualität

Background

The outcome of cardiopulmonary resuscitation (CPR) depends on the quality of chest compressions. Current European Resuscitation Council (ERC) guidelines promote the development of feedback systems. However, no studies presenting satisfactory results of feedback use have been published.

Methods

A total of 60 patients with cardiac arrest (≥18 years of age) received resuscitation attempts using an automated external defibrillator (AED) with real-time feedback by the ambulance service of the City of Münster. The frequency of chest compressions, no-flow time (NFT) and depth of chest compressions were analyzed for the first three cycles of CPR and compared to the ERC guidelines 2005.

Results

Chest compression frequency did not differ significantly from the ideal as set out in the guidelines. Analysis of NFTs showed significantly longer NFT for the first cycle but NFT for the second and third cycles did not differ significantly from the ideal. The target depth of 4-5 cm was achieved in 80% of all chest compressions in the first 3 cycles.

Conclusion

With the AED real-time feedback technology used in this study standardized performance of chest compressions could be maintained in a professional ambulance service. Implementation of a feedback system requires training of ambulance staff.     

Muskelrelaxanzien, Intubationsqualität und laryngeale Morbidität

Ohne Zusammenfassung     

Hintere Knieinstabilität

Zusammenfassung Durch verbesserte Methoden der Diagnostik werden gegenwärtig hintere Knieinstabilitäten häufiger erkannt. Bis heute ist jedoch der natürliche Verlauf der isolierten Ruptur des hinteren Kreuzbandes nicht exakt bekannt. Nach konservativer Behandlung treten erste arthrotische Veränderungen erst nach ca. 10–15 Jahren auf. Davon sind v. a. das Femoropatellargelenk und das mediale Kompartment betroffen. Bei den komplexen Instabilitäten mit Läsionen der Sekundärstabilisatoren sind die posterolaterale Gelenkecke und das laterale Seitenband, aber auch die Beinstatik besonders wichtig. Die konservative oder operative Behandlung hängt ab vom Ausmaß der Verletzung, von den mitbetroffenen Begleitstrukturen und der Beeinträchtigung des Patienten. Bei den Ersatzplastiken des hinteren Kreuzbandes werden am häufigsten Transplantate aus der Patellar-, Quadrizeps-, Semitendinosus- und Grazilissehne verwandt. Bei gleichzeitiger Schädigung der posterolateralen Ecke des Kniegelenks sind zusätzliche bandstabilisierende Maßnahmen notwendig.     

Myotoxizität von Lokalanästhetika

Intramuscular injections of local anaesthetic agents regularly result in reversible muscle damage, with a dose-dependent extent of the lesions. All local anaesthetic agents that have been examined are myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury. The histological pattern and the time course of skeletal muscle injury appear relatively uniform: hypercontracted myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic reticulum myocyte edema and necrosis. Intriguingly, in most cases myoblasts, basal laminae and connective tissue elements remain intact which subsequently ensures complete muscular regeneration. Subcellular pathomechanisms of local anaesthetic myotoxicity are still not understood in detail. Increased intracellular Ca(2+) levels are suggested to be the most important element in myocyte injury, since denervation, inhibition of sarcolemmal Na(+) channels and direct toxic effects on myofibrils have been excluded as sites of action. Although experimental myotoxic effects are impressively intense and reproducible, only few case reports of myotoxic complications in patients after local anaesthetic administration have been published. In particular, the occurrence of clinically relevant myopathy and myonecrosis has been described after continuous peripheral blockades, infiltration of wound margins, trigger point injections, peribulbar and retrobulbar blocks.     

Strahlentherapieassoziierte Morbidität und Mortalität in der Rektumchirurgie

The treatment of rectal cancer has evolved significantly in recent decades. Both modern radiotherapy treatment concepts and surgical techniques have been able to improve oncological as well as functional outcomes for rectal cancer patients. Large-scale, multicenter, randomized trials have been able to demonstrate the benefits of neoadjuvant treatment over adjuvant radiotherapy. In addition, local tumor control is improved by neoadjuvant irradiation. Conversely, patients receiving a total mesorectal excision showed no survival advantage following irradiation vs. only surgically resected patients. In addition, radiation therapy is associated with a certain morbidity and mortality. This paper summarizes the available evidence regarding postoperative morbidity, mortality, and long-term chronic effects of neoadjuvant radiotherapy.     

Die Arnold-Chiari-Deformität

Zusammenfassung Bericht und Diskussion über klinische Beobachtungen beim Arnold-Chiari-Syndrom. Besprechung der sich ergebenden Fragen in diagnostischer, therapeutischer sowie pathogenetischer Hinsicht. Versuch einer Einteilung der verschiedenen Syndromvarianten.Mit 16 Textabbildungen in 30 Einzeldarstellungen     

Patientengefährdung durch Gerätediversität?

Background

The Federal Institute for Drugs and Medical Devices (BfArM) was notified of an event in which it was not possible to sufficiently ventilate a patient suffering a severe asthma attack. It turned out that the ventilation pressures used by the device for pressure-controlled ventilation were below the values set by the user, which the user was not aware of. The ventilation pressures chosen by the user exceeded the preset alarm limits of the ventilator. This pressure and alarm management significantly differed from that of other ventilators used in the hospital. This and similar incident reports suggest that safely operating medical devices for anesthesia and intensive care may be impaired when different models of a device are used within a hospital. If different models are used, more device information needs to be stored in memory. Existing knowledge on human memory suggests that the more individual memory items (e.?g. different operating rules) are stored, the greater the risk of memory interference and hence of impaired retrieval, particularly if the different items are associated with overlapping retrieval cues. This is the case when different devices are used for a single functional purpose under identical or similar circumstances.

Objective

Based on individual incident reports and theoretical knowledge on an association between device diversity and use problems, this study aimed to determine the organizational conditions regarding device diversity that prevail in German hospitals. Additionally, the anesthetists’ perspectives and experiences in defined clinical settings were investigated.

Methods

For selected groups of medical devices, the biomedical engineers of German hospitals were surveyed about the different makes used in their hospital. Additionally, questionnaires were sent to a department of anesthesiology of a large University Hospital to investigate the personal experiences of working with different makes and models of a device.

Results

Using devices by different manufacturers was particularly frequent for ventilators, but there were also a considerable number of hospitals with syringe pumps and patient monitoring systems from different manufacturers. Almost all participants stated that they work or have worked with different models of a device. The majority of respondents had encountered problems or errors, which they ascribed to the requirement to learn a different method of operation for each device; however, they also listed various benefits, for instance the possibility to optimally address the requirements of specific situations or patient groups. Both biomedical engineers and anesthetists suggested a homogeneous device pool within the hospital and regular and repeated training sessions for each device model used.

Discussion

Using different device models for anesthesia and intensive care seems to be common in many German hospitals, particularly for ventilators. An association between device diversity and problems operating a device is plausible, given the functioning of human memory. This topic should be investigated by future studies in order to identify factors that may contribute to such problems and possible solutions for clinical settings. Likewise, the potential benefits of having different device models at one’s disposal should be evaluated. To pinpoint the measures that will be most effective given the specific settings of the individual hospital, all underlying clinical and economic considerations must be carefully balanced against the associated potential risks.

     

Effektivität einer neuen Wärmedecke

Background

Perioperative hypothermia is a common complication of general anesthesia and occurs in up to 50?% of patients during ear, nose and throat (ENT) surgery. In this prospective, randomized controlled study the hypothesis that a new conductive warming blanket (Barrier® EasyWarm®, Mölnlycke Health Care Erkrath, Germany) is better in reducing the incidence of perioperative hypothermia in ENT surgery than insulation with a conventional hospital duvet alone was tested.

Materials and methods

After approval of the local ethics committee and written informed consent 80 patients with a planned procedure time between 1 and 3 h were recruited. Anesthesia was induced and maintained using propofol, remifentanil and rocuronium and the core temperature was measured using an esophageal temperature probe. Patients in the study group were warmed at least 30 min prior to induction of anesthesia using the novel warming blanket (Barrier® EasyWarm®) and patients in the control group were insulated with a standard hospital duvet. Data were tested using Fisher’s exact test, Student’s t-test or the Mann-Whitney U-test as appropriate. Time-dependent changes in core temperature were evaluated using repeated measures analysis of variance (ANOVA) and post hoc Scheffé’s test. Results are expressed as mean ± SD or as median and interquartile range (IQR) as appropriate. A p?<?0.05 was considered to be statistically significant.

Results

The ANOVA did not identify a significantly higher core temperature in the study group at any time point. Furthermore, Fisher’s exact test showed no differences in the incidence of intraoperative (12 out of 29 versus 10 out of 32 patients, p?=?0.44) or postoperative hypothermia (12 out of 29 versus 9 out of 32 patients, p?=?0.30) between the groups. No adverse effects were observed.

Conclusions

In the studied patient group the new conductive warming blanket (Barrier® EasyWarm®) showed no superiority compared to conventional thermal insulation alone.     

Qualität der BQS-Dokumentation

Background

The BQS is a nationwide quality assurance program in Germany. The aim was to evaluate the data quality on intra-operative and postoperative complications for cholecystectomy submitted to the BQS.

Patients and methods

For 205 patients who underwent cholecystectomy in 2007 complications were retrospectively evaluated and compared with those documented in the BQS database. Additionally the risk factors for complications were documented.

Results

A total of 205 patients were included in the study. In 88% of patients the operations were initiated as laparoscopy and the conversion rate was 8.3%. Of the patients 28 suffered from intra-operative or postoperative complications. There were no injuries to the ductus hepatocholedochus (DHC). The most common operation-specific complications were disorders in wound healing (n=7). Multivariate analyses resulted in significant increases in complication rates for ASA status (Odds ratio 3.29, 95% confidence interval 2.12–5.10, p<0.01) and acute cholecystitis (odds ratio 7.71, 9% confidence interval 2.96–20.08, p<0.01). Only 13 patients out of 28 were correctly documented in the BQS database (p<0.01). Sensitivity and specificity for complications were 46 and 98%, respectively.

Conclusions

Less than half of all cases were correctly documented in the BQS database. If documentation inthe BQS database was equally poor for all German surgical departments, neither benchmarking nor general conclusions on quality of surgical care could be drawn from the BQS data.     

Pathomorphologie der Schulterinstabilität

In cases of a traumatic anterior first-time dislocation of the shoulder, pathomorphological changes may initially occur at three different sites: at the capsule itself, at its origin or at its insertion. The typical injury is an avulsion of the labrum and the capsule from the glenoid and is called a Bankart lesion. There is a tendency to underestimate the amount of plastic deformation of the capsule and alternative injuries, such as avulsion of the capsule from the humeral head (HAGL lesion). Bony deformities at the humeral head or at the glenoid are of utmost importance for the prognosis of shoulder instability. In the dislocated position the anterior glenoid rim may notch the posterior surface of the humeral head (Hill-Sachs lesion). Bony defects of the glenoid may be caused by a fracture or due to chronic wear (fracture or erosion type). If bony defects exceed a certain size, isolated reconstruction of soft tissues does not guarantee stability of the shoulder.     

Lebensqualität nach Polytrauma

Background

Multiple trauma is an independent injury pattern which, because of its complexity, is responsible for 25?% of the costs for the treatment of all injured patients. Because of the often long-lasting physical impairment and the high incidence of residual permanent handicaps, it is apparent that multiple trauma can lead to a reduction in patient quality of life.

Objectives

The aim of this study was to give an overview of the known data concerning the change in quality of life for multiple trauma patients. Furthermore, predictors for the reduction of quality of life after multiple trauma will be identified.

Materials and methods

A MedLine search was performed to identify studies dealing with the outcome after multiple trauma.

Results

In addition to functional outcome parameters, the term quality of life has become more important in recent years when it comes to evaluating the outcome following injury. While the mortality after multiple trauma could be significantly reduced over the years, there is no comparable effect on the quality of life. Predictors for a worse quality of life after multiple trauma are female gender, high age, low social status, concomitant head injuries and injury to the lower extremities.

Conclusion

The fact that mortality after multiple trauma has decreased but not impairment of the quality of life makes it clear that in addition to the acute medical treatment, a follow-up treatment including not only physiotherapy but also psychotherapy is crucial for multiple trauma patients.     

Orchitis und Infertilität

Infections and inflammations of the genital tract are considered the most frequent causes of reduced male fertility, but conclusive epidemiological data are not available. In view of the exposure of germ cells to pathogenic components as well as the cells and mediators involved in the inflammatory processes, irreversible damage to spermatogenesis and corresponding decline of ejaculate quality are to be expected, particularly in cases of chronic orchitis. While the consequences of orchitis and epididymo-orchitis that exhibit clinical symptoms due to systemic or local infections are well known, including testicular atrophy and complete loss of fertility, those cases of inflammatory reactions of the testicles that manifest an asymptomatic or subclinical course, or are not even due to an infection, have received little attention until now. However, systematic histopathological analyses have shown a high prevalence of asymptomatic inflammatory reactions in testicular biopsies from infertile men. The mostly focal lymphocytic infiltrates correlate with the degree of damage to spermatogenesis and corresponding clinical and endocrinological parameters of testicular function. Noninvasive diagnostic techniques are not yet available so that chronic asymptomatic inflammations of the testicles as the primary cause or cofactor of male fertility disorders are underestimated. Except for administration of pathogen-specific antibiotics, treatment recommendations are to a large extent still lacking.     

Sexualität im Alter

The demographic development in the western industrial societies makes the quality of life of older people a very important issue. Leading a satisfying sexual life is part of this. The picture of older people as asexual humans can no longer be maintained.Recent studies show that the fundamental psychosociological need for acceptance, tenderness, warmness and security does not disappear with age. Sexual activity in the age primarily depends on the existence of a partnership. Sexual dysfunctions in aging result from physical, psychological, and partner-related changes, as well as lifestyles. This has to be considered in diagnosis and treatment. Principally, there is no difference between the treatment of older and younger sexual partners     

Ohrakupunktur bei Detrusorhyperaktivität

Background

Patients suffering from overactive bladder/detrusor overactivity (OAB/DO) seem to benefit from body acupuncture. The study was carried out to test if auricular acupuncture (AAP), which is supposed to show an immediate effect, can also cause urodynamic changes.

Patients and methods

The OAB/DO condition was verified by means of cystometry in 14 patients. These patients were subjected to bilateral AAP after cystometry, a second cystometry was performed 20-30 min later and data were analyzed using the Wilcoxon rank-sum test.

Results

None of the patients showed local or systemic complications but DO persisted in all patients and urge urinary incontinence (UUI) persisted in 85 % (11/13) of patients. Intravesical pressure decreased after AAP but without reaching statistical significance. In 22 % (2/9) of patients residual volume (RV) disappeared completely while 78 % (7/9) of patients showed significant reduction of RV.

Conclusions

This study could not prove a significant influence of AAP on DO or UUI; therefore an immediate effect of AAP in patients suffering from OAB/DO seems to be unlikely. Further studies are necessary to evaluate the effect of repeated AAP sessions on urodynamic changes.     

Sexualität nach Nierentransplantation

The quality of life of patients after kidney transplantation is of increasing interest. In this connection, issues of sexuality are meaningful too. Many patients with end-stage kidney disease suffer from sexual disorders. More than 50% of the male patients on dialysis and even more females are affected by disturbances such as erectile dysfunction and loss of libido or abnormal menstrual cycles. After successful kidney transplantation most symptoms in women are improved, whereas in men disturbances in erectile function often persist or even deteriorate. In these patients treatment with inhibitors of phosphodiesterase type 5 is a valid option with an effective response. In women with stable graft function pregnancy can be achieved successfully. Nevertheless, pregnant kidney allograft recipients should be considered as high-risk patients needing special care under the supervision of a team of obstetricians and nephrologists.     

Operative Interdisziplinarität. Extremitäten

From the perspective of trauma and orthopedic surgery interdisciplinary reconstructive surgery of the extremities encompasses different indications ranging from IIIB/Copen fractures with major segmental loss of bone and soft tissue, to arterial vessel in-jury necessitating vascular repair and to biological, plastic reconstructions following resections of musculoskeletal tumors. The interdisciplinary treatment concept including trauma-orthopedic surgery combined with vascular, plastic and neuro- as well as microsurgery has significantly decreased amputation rates and functional deficits thereby improving quality of life and long-term oncological outcome The multisdisciplinary management of both complex trauma and malignant bone/ soft tissue sarcoma of the extremity is an integral task of the surgical trauma or tumor center. Close interdisciplinary communication and expierence are the precondition for performance of a priority-adapted therapeutic strategy, low complication rates and improvement of overall prognosis.     

Dignität von Glomus-caroticum-Tumoren

Introduction

Tumors of the carotid body are rare paragangliomas (incidence 0.012%) originating from sympathetic fibres of the carotid bifurcation. Growth is slow and they frequently become symptomatic through local mechanical compression of neighboring vascular and neural structures. The aim of this study is to present the diagnosis, therapy and course in patients with a carotid body tumor treated at our department of the Düsseldorf University Hospital and to discuss rates of recurrence and also dignity during the long-term follow-up.

Patients and methods

Included in this retrospective study were all patients treated for a carotid body tumor between January 1988 and June 2008. At follow-up examination the current history was recorded and a physical examination, sonography and duplex sonography were carried out. Furthermore each patient completed the questionnaires QLQ-C30 of the European Organisation for Research and Treatment of Cancer (EORTC) and the module for head and neck QLQ-H&N35 to assess quality of life.

Results

In our collective of 36 patients consisting of 13 men (36%) and 23 women (64%) with an average age of 48.33 years (range 17–78 years), 16 patients presented with a local neck swelling and 5 patients each had difficulties swallowing or hoarseness, respectively. Preoperatively Horner’s syndrome was found in one patient. A total of 22 tumors were found on the right side of the neck (52.38%), 20 were found on the left side (47.62%) and 6 patients showed a bilateral carotid body tumor (16.67%), 3 of which were bilaterally excised. The other 3 patients are still under surveillance without surgery. Altogether surgery of 39 carotid body tumors was performed in 36 patients. In all 39 cases (primary surgery n=34, recurrence surgery n=5) the tumors were macroscopically excised in toto. Parts of the vagus nerve had to be resected in 3 patients (7.69% Shamblin type II n=1, Shamblin type III n=1) and resection of blood vessels was necessary during 10 operations. The survival rate after 1 year was 100%, after 2 years 96.3% and after 5 years 92.6%. A local recurrence was diagnosed in 2 patients (5.13%). In one patient a second operation was necessary and in the other patient there was a non-progressive swelling in the carotid bifurcation which had existed for 14 years and which was conservatively left untreated. Peripheral neural lesions could be found in 12% (3/25) at long-term follow-up. None of the patients showed evidence of local or remote metastasization of a carotid body tumor.

Conclusions

Surgical extirpation of carotid body tumors can be regarded as the only curative option with an overall mortality of 0%. Morbidity is low when applying vascular surgical techniques (2.56% for central lesions). The incidence of peripheral nervous lesions is high reflecting the radicality of the resection (64.10%) but is outweighed by the benefits. In the long-term follow-up the rate of permanent peripheral neural lesions decreased to 12%. Due to a potentially infiltrating and disseminating growth, carotid body tumors should be regarded as semi-malignant and should therefore be indicated for surgery at the time of diagnosis. Whether the incidence of carotid body tumors will rise due to increased routine diagnostic examination of the head and neck region using sonography and tomography remains to be seen.     

Chronische obere Sprunggelenkinstabilität

Background

It is often difficult in the acute phase to diagnose a lesion of the distal tibiofibular syndesmosis. If this lesion is overlooked, the patient will develop an incongruity of the upper ankle joint with a pathological external rotation of the talus. The risk of a possible premature arthritis is clearly increased.

Objectives

In this case study a distal rupture of the syndesmosis in a young patient was overlooked in the initial diagnostic work-up.

Methods

A search of the relevant literature and a case report.

Results

In the case described the shortened fibula and chronic instability of the tibiofibular syndesmosis were repaired with a lengthening and derotational osteotomy and reconstruction using the gracilis muscle tendon. Through this method an exact reconstruction of the normal anatomy could be achieved.

Conclusion

Posttraumatic misalignment in the ankle joint is associated with a high risk of secondary degenerative lesions. In cases with suspicion of a syndesmosis lesion, confirmation of the diagnosis is imperative so as to perform an anatomic repositioning and reconstruction of stability.     

Die Chronische Symphyseninstabilität

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.