Browsing by Author "Spies, C."

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities.However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

Critical care medicine usually involves the implementation of measures resulting in significant consequences for the patient - including possible mistakes arising directly or indirectly from daily routine processes. In addition, an ever-widening range of pharmaceutical and technological options may also often have an impact. The increasing complexity of pharmaceuticals and technical aids must be monitored and taken into account. The need for 24-hour care requires the daily presence of a variety of IC specialists and the interchange of data. Immediate coordinated expert action is equally as important as professional competence in dealing with current limitations of medical science. Intensivists are increasingly being confronted with the demands of professional quality management requirements within the ICU. This aspect is highlighted by the Vienna declaration on ICU patient safety drawn up at the 2009 European Congress of the ESICM [1]. This includes a commitment to actively pursue quality management within the setting of intensive care medicine. The present article describes a practical and effective approach to this complex subject matter and the external evaluation of critical care by peer review, which has already been successfully implemented in Germany and is set to gain in significance.

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1(st) revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the "German Instrument for Methodological Guideline Appraisal" of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Eine Sepsis ist eine akut lebensbedrohliche Organdysfunktion, hervorgerufen durch eine inadäquate Wirtsantwort auf eine Infektion. Für die Diagnose einer Sepsis-assoziierten Organdysfunktion ist eine Veränderung des Sequential Organ Failure Assessment (SOFA)-Scores um ≥ 2 Punkte zu verwenden. Zur hämodynamischen Stabilisierung von Patienten sollte eine intravenöse kristalloide Lösung innerhalb der ersten 3 Stunden verabreicht werden. 0,9 %ige Kochsalzlösung sollte NICHT verwendet werden. Eine schematische Mindestinfusionsmenge und ein allgemeiner Zielwert für den mittleren arteriellen Blutdruck werden nicht empfohlen. Intravenöse Antiinfektiva sollten so schnell wie möglich verabreicht werden – möglichst innerhalb 1 Stunde nach Diagnosestellung. Um alle wesentlichen Bakterien zu erfassen, wird die Anwendung einer empirischen Breitspektrumtherapie mit einem oder mehreren Antibiotika empfohlen. Um die antimikrobielle Therapiedauer zu verkürzen, sollten Messungen des Procalcitonin-Werts vorgenommen werden.

Background: The effect of non-pulsatile, normothermic cardiopulmonary-bypass (CPB) on the splanchnic blood-flow and oxygen-transport, the hepatic function and the gastrointestinal barrier were observed in a prospective observational study in 31 adults undergoing cardiac valve replacement surgery. Methods: The splanchnic (i.e. hepatic) blood-flow (HBF) was measured by the constant infusion of indocyanine-green (ICG) using a hepatic-venous catheter. Liver function was examined by calculation of lactate uptake, ICG extraction and the monoethylglycinexylidide (MEGX) test. A day before and after surgery the gastrioduodenal and intestinal permeability was measured by determination of sucrose and lactulose/mannitol excretion. Results: Splanchnic blood flow and oxygen delivery did not decrease during and after surgery while splanchnic oxygen consumption (P < 0.0125) and arterial lactate concentrations increased. The splanchnic lactate uptake paralleled the lactate concentration. After but not during CPB an increase of systemic oxygen consumption was observed. The MEGX test values decreased on the first day after surgery. The ICG extraction was attenuated during the operation. The gastroduodenal and the intestinal permeability increased significantly postoperatively (P < 0.002, respectively, P < 0.001). There was no correlation between these findings and the duration of CPB. There was a significant correlation of the intestinal permeability but not of the gastroduodenal permeability between the prior and after surgery values (P < 0.001). Conclusion: Increased oxygen consumption during CPB may indicate an inflammatory reaction due to the pump beginning in the splanchnic area or a redistribution of the splanchinc blood flow during the CPB. Normothermic CPB does not lead to a significant or prolonged reduction of liver function. Normothermic CPB causes an increase of gastrointestinal permeability. The intestinal barrier function prior to surgery was accountable for the degree of loss of intestinal barrier function following surgery.

The introduction of a contribution coverage calculation as an instrument for evaluating economic efficiency implies a correct distribution of earnings to the various hospital departments involved in the treatment of the patient. In this connection, special importance attaches to intensive care problems with the implemented systems for earnings distribution are, on the one hand the focus on primary costs resulting in neglect of the internal budgeting system, and on the other a system that rewards the rapid transfer of the patient from the intensive care department. The system presented herein describes a concept that distributes all earnings recorded in the calculation matrix, and thus enables a setting off of costs from the internal budgeting system. At the same time, the lump-sum allocation of earnings to the sections ICU and normal wards ensures that a prolongation of stay in a particular treatment sector offers no incentive in terms of increased earnings.