Abgrenzung der Verantwortung für die operative Lagerung des Patienten und Haftung für Lagerungsschäden

The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation. Faults in organization are regarded under the law as faulty treatment. Anaesthetist and surgeon are each responsible for their own errors. According to the interdisciplinary agreements, positioning and checks on position are the task of the surgeon, while the anaesthetist is responsible for the "infusion arm". This does not exclude the possibility that anaesthetist and surgeon may agree on a different division of labour in the operating room. The patient bears the burden of proof that errors were committed in a case for damages. The doctor does, however, have to prove that the patient was correctly positioned. The demands of jurisdiction in terms of documentation of the positioning and of presentation of evidence are practically oriented and can basically be met. The same is true of the information supplied to the patient on the risk that positioning can cause harm. The doctor is obliged to supply evidence of the patient's substantive consent and the provision of information that this implies.     

Abgrenzung der Verantwortung für die operative Lagerung des Patienten und Haftung für Lagerungsschäden

The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation. Faults in organization are regarded under the law as faulty treatment. Anaesthetist and surgeon are each responsible for their own errors. According to the interdisciplinary agreements, positioning and checks on position are the task of the surgeon, while the anaesthetist is responsible for the "infusion arm". This does not exclude the possibility that anaesthetist and surgeon may agree on a different division of labour in the operating room. The patient bears the burden of proof that errors were committed in a case for damages. The doctor does, however, have to prove that the patient was correctly positioned. The demands of jurisdiction in terms of documentation of the positioning and of presentation of evidence are practically oriented and can basically be met. The same is true of the information supplied to the patient on the risk that positioning can cause harm. The doctor is obliged to supply evidence of the patient's substantive consent and the provision of information that this implies.     

Grundsätze für die Behandlung und Eingliederung Querschnittsgelähmter

Zusammenfassung Die Absicht unserer Ergänzung ist es, klarzustellen, daß die Richtlinien für die Rehabilitation Querschnittsgelähmter dem heutigen Stand unseres Wissens entsprechend fertig ausgearbeitet und in der Praxis erprobt vorliegen. Es ist unsere Absicht, weiterhin darauf hinzuweisen, daß trotz aller ernsthaften und dankenswerten Bemühungen die Erfolge, die nach diesen Richtlinien erreicht werden können, noch nicht bei uns erzielt werden können oder gar Allgemeingut sind. Man soll weiterhin darauf hinweisen, daß die gleichen Ergebnisse, wie sie z. B. in England auf diesem Gebiet erzielt werden —, und die mit Abstand besser sind als die bei uns üblichen — jederzeit auch bei uns reproduziert werden können, wenn die Voraussetzungen dafür geschaffen werden. Diese Voraussetzungen sind vor allem solche organisatorischer und wirtschaftlicher Natur und es kann nicht klar genug herausgestellt werden, daß an diesem Punkte die Lösung des Problems angefaßt werden muß, weil von hier aus allein die Reproduktion der besseren Ergebnisse möglich ist. Das Problem ist also heute, wenn wir uns dem Stand anderer zivilisierter Nationen angleichen wollen, weit weniger ein medizinisches (denn die Behandlungsgrundsätze liegen klar zu Tage), sondern die Aufgabe ist eine organisatorische, verwaltungstechnische und wirtschaftliche.     

Grundsätze für die Behandlung und Eingliederung Querschnittsgelähmter

Zusammenfassung Für die einzelnen Behandlungsabschnitte, die der Wiedererlangung der Lebenstüchtigkeit total Querschnittsgelähmter dienen, werden auf Grund fremder und eigener Erfahrungen Anregungen gegeben, die geeignet sind, drohende Komplikationen verhindern, eingetretene Störungen beseitigen und bestmögliche Ergebnisse der Eingliederung erzielen zu helfen. Die Hinweise betreffen die Frühbehandlung, die — wie auch die Erstversorgung — unter den derzeitigen Verhältnissen zahlreichen Krankenhäusern überlassen ist, und die Weiterbehandlung, die möglichst auf besonderen Stationen in größeren Gruppen erfolgen soll. Auf die Verpflichtung, durch Einsatz aller Möglichkeiten, insbesondere von bewährten Behandlungsmethoden, modernen Hilfsmitteln sowie von Sport und Spiel über die Erhaltung des Lebens hinaus diesem neue Werte zu geben, wird hingewiesen.Mit 7 Textabbildungen     

Die ambulante Behandlung von Knochenbrüchen mit Gipsverbänden und Distraktionsklammern

Ohne Zusammenfassung (Mit 9 Abbildungen.) Auszugsweise vorgetragen am 4. Sitzungstage der 42. Versammlung der Deutschen Gesellschaft für Chirurgie zu Berlin, M?rz 1913, unter Demonstration von 3 Knochenbruchpatienten, bei welchen die Distraktionsklammern vor 8 Tagen angelegt waren.     

Einflussfaktoren und Prädiktoren für die ungeplante stationäre Aufnahme tageschirurgischer Patienten

In order to plan the daily routine of a surgical day care unit optimally and effectively, it is indispensable to know the causes of unanticipated admission of outpatients. The purpose of this experiment was to evaluate the influences and predictors of unanticipated admission of patients in our day care unit for ambulatory surgery. The data sets of 3152 surgical outpatients were evaluated. The duration of stay had been entered online by computers. METHOD: From January 1997 until June 1999, all clinically relevant parameters from any outpatient were entered into an anesthesia information management system (NarkoData, Imeso GmbH, Hüttenberg-Rechtenbach, Germany). The correlation of potential nominal and ordinal scaled predictors of unanticipated admission was tested using the chi-squared test. Univariate analysis was used in determining predictors for the occurrence of unanticipated admission. Pearson's contingency coefficient (CC) was used as a standard for the correlation rigidity in nominal and ordinal scaled parameters. The correlation standard eta was used for metrical parameters. RESULTS: Unanticipated admission occurred in 169 (5.4%) of the 3152 outpatients. The following parameters significantly influenced unanticipated admission: age, ASA status, diagnosis (ICD-9), time of admission, different anesthesia procedures and anesthetics (opioids and non-depolarizing muscle relaxants), surgical department, type of surgery (ICPM), duration of operation, blood loss, intraoperative hemoglobin values, and the administration of colloid and crystalloid solutions. The parameters blood loss, intraoperative hemoglobin values, and administration of colloid solutions were evaluated as being good predictors. CONCLUSION: The causes of unanticipated admission of patients in our day care unit for ambulatory surgery are manifold. Some relate to the patient, the anesthesia, and the organization of the day care unit, whereas lengthy operative trauma leading to intraoperative blood loss also plays a major role.     

Potenzielle Determinanten für poststationäre ambulante Therapiekosten chronischer Wunden

Background

The results of international studies have shown a higher quality of care as well as cost savings in the outpatient treatment of chronic wounds through the application of integrative care models.

Patients and methods

The Wound Competence Network Middle Upper Rhine was founded in 2006 with the aim of introducing structured post-hospital wound management and wound treatment algorithms across all involved medical sectors. Meanwhile, the data of 450 patients are available.

Results

Incomplete or non-evaluable records revealed deficiencies in the cross-sector sharing of information. The introduction of a revised database TOMORROW improved the documentation and interpretability. The analysis of a patient sample (n?=?123) showed an average treatment cost of € 1551.20 per patient and year with an imbalance in the distribution. The treatment of 75?% of the patients required less than the average cost but 10?% of patients caused an average cost of € 9248.70 per patient and year (63?% of total costs). Obesity and multimorbidity were statistically associated with higher expenses of therapy. No relation to the costs of care could be found for age and sex.

Conclusion

Individual treatment results and costs vary greatly in outpatient wound therapy. This is associated with factors and measures, the understanding of which will probably make cost savings possible. A precondition is a high level of wound documentation.     

Anästhesie für Herzkatheteruntersuchungen bei Kindern

Cardiac catheterization in children with congenital heart disease or in adults with completely or partially corrected cardiac defects, is a growing field of activity for anaesthesiologists. This requires not only the willingness for interdisciplinary co-operation, but also detailed knowledge about the pathophysiology of congenital heart diseases. In interventional paediatric cardiology significant innovations have occurred during recent years including stenting of a patent ductus arteriosus and of peripheral pulmonary artery stenosis. Furthermore, radiofrequency catheter ablation for recurrent tachyarrhythmia, or resynchronisation therapy with biventricular pacing in the setting of congestive heart failure, or implantation of cardioverter defibrillators are increasingly being employed which require anaesthesia support.     

Trikot-Ärmelschluß für Operationsmäntel

Ohne Zusammenfassung (Mit 1 Abbildung.)     

Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte

Objective

Treatment of large dia- and metaphyseal bone defects (>?3 cm) with two surgical interventions with an interval of 4–8 weeks.

Indications

Dia- and metaphyseal bone defects predominantly of the lower extremity.

Contraindications

Intraarticular bone defects, persisting bone infection or osteomyelitis, insufficient soft tissue coverage in the region of the bone defect, osteoporosis.

Surgical technique

First surgical intervention: thorough bone debridement and soft tissue coverage, implantation of a cement spacer into the bone defect for the induction of a synovial foreign-body membrane, internal or external fixation. Second surgical intervention: removal of the cement spacer and filling of the bone defect with autologous cancellous bone graft, optionally internal fixation after initial external fixation.

Postoperative management

Partial to full weight-bearing after the first surgical intervention depending on pain. Partial weight-bearing (max. 15 kg) after the second surgical intervention, until radiological signs of a remodeling of the regenerate bone occur. Usually no implant removal.

Results

A total of 6 patients (4 men, 2 women) aged 15–66 years with average bone defects of 7 cm (range 4–10 cm) were treated using the Masquelet technique. There were 2 aseptic femoral nonunions and 4 tibial nonunions (2 septic and 2 aseptic nonunions). One case was a periprosthetic tibial bone defect. Bone stabilization after debridement was performed using ring fixators on the tibia and an intramedullary nail and a locking plate on the femur, respectively. The second surgical intervention was performed after 6–9 weeks. In 3 of the 4 tibial cases, internal fixation was performed during this intervention. The iliac crest and the RIA (reamer–irrigator–aspirator) technique were used for cancellous bone grafting. Amputation after breakage of the plate was necessary in the patient with the periprosthetic bone defect. Nonunion at the docking site required cancellous bone grafting in 1 patient. All 5 patients were able to perform full weight-bearing without pain after 6 months. The Ilizarov fixator was removed 5 months after the second surgical intervention in a 15-year-old patient. None of the other implants were removed.

     

Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und primärer Hüfttotalprothese

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring.Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement.All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident.Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.     

Plädoyer für die primäre Resektion mit primärer Anastomose bei der komplizierten Sigmadiverticulitis

Zusammenfassung Von 1973 bis 1986 wurden 107 Patienten mit einer komplizierten Sigmadiverticulitis operiert. Es handelte sich um 47 Frauen und 60 Männer bei einem Durchschnittsalter von 62 Jahren. Von 107 Patienten wiesen 14 eine perforierte Diverticulitis mit diffuser eitriger/kotiger Peritonitis auf, 68 Patienten eine perforierte Diverticulitis mit lokalisierter eitriger Peritonitis/paracolischem Absceß und 25 Patienten eine akute phlegmonöse Diverticulitis ohne Perforation. Zusätzliche pathologische Befunde waren: innere Fisteln (13 Patienten), nekrotisierende Fasciitis (3 Patienten), Stenose mit Ileus (3 Patienten) und synchrone Carcinome (7 Patienten). Die Gesamtletalität der 107 Patienten betrug 9,3% (=10 Patienten), die Morbidität der 97 überlebenden Patienten 34,0% (= 33 Patienten). Die Letalität bei 14 Patienten mit perforierter Diverticulitis und diffuser eitriger/kotiger Peritonitis lag bei 50%, die der 68 Patienten mit perforierter Diverticulitis und lokaler eitriger Peritonitis/ paracolischem Absceß bei 4,4%, die der 25 Patienten mit akuter phlegmonöser Diverticulitis ohne Perforation bei 0%. Von den 10 Patienten verstarben 7 bei Operation ihrer perforierten Diverticulitis mit diffuser eitriger Peritonitis, 1 (5) nach primärer Resektion mit primärer Anastomose, 3 (5) nach Operation nach Hartmann, 3 (4) nach alleiniger Anlage einer Colostomie. Bei Operation der perforierten Diverticulitis mit lokaler Peritonitis verstarben 3 Patienten, 2 (6) nach Operation nach Hartman und 1 (5) nach alleiniger Anlage einer Colostomie. Trotz einer hohen Zunahme der Zahl primärer Resektionen mit primärer Anasto mose im Zeitraum 1980–1986 ergab sich im Vergleich zum 7-Jahresabschnitt 1973–1979 ein Rückgang der Letalität von 35,7% auf 0% bei dieser Operation. Ihre Anwendung ist auch gerechtfertigt bei der perforierten Diverticulitis mit lokaler wie diffus eitriger oder kotiger Peritonitis.

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Primary resection with primary anastomosis in complicated diverticulitis of the sigma

Summary Of the 107 patients with complicated diverticulitis operated from 1973–1986 47 were females and 60 males. In 14 of the 107 patients a perforated diverticulitis with diffuse purulent/faecal peritonitis was found, a perforated diverticulitis with localized purulent peritonitis/paracolic abscess in 68 patients and an acute phlegmonous diverticulitis without perforation in 25 patients. Additional pathologic findings were internal fistulae (13 patients), necrotizing fasciitis (3 patients), obstruction (3 patients) and synchronous carcinoma (7 patients). The overall mortality of the 107 patients was 9.3 % (=10 patients) and the morbidity of the 97 survivors 34% (=33 patients). The mortality of the 1.4 patients with perforated diverticulitis and diffuse purulent peritonitis was 50%, of the 68 patients with perforated diverticulitis and localized purulent peritonitis 4.4% and of the 25 patients with acute phlegmonous diverticulitis 0%. Seven of the 10 patients died after operation of the perforated diverticulitis with diffuse purulent peritonitis — 1 (5) after primary resection with primary anastomosis, 3 (5) after Hartmann procedure, 3 (4) after loop colostomy alone. Three patients died after operation of the perforated diverticulitis with localized purulent peritonitis — 2 (6) after Hartmann procedure, 1 (5) after loop colostomy alone. In spite of forcing the primary resection with primary anastomosis in the years from 1980–1986 the mortality decreased for these operations from 35.7% in 1973–1979 to 0% in 1980–1986. The indication of primary resection with primary anas tomosis is justified also for perforated diverticulitis with localized and diffuse peritonitis.

Auszugsweise vorgetragen auf dem Symposium Entzündliche Darmerkrankungen der Medizinischen Akademie Carl Gustav Carus, Dresden, 20. November 1987     

Normalien für Anschlußstücke zur Befestigung des Armgerätes an der Bandage und für Riemenverbindungsschrauben—Riemen-Drehniete

Ohne Zusammenfassung Mit 14 Abbildungen im Text.     

Modelle und Paßteile für Amputation des Unterschenkels

Ohne Zusammenfassung