[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]. / Ist die Fachrichtung assoziiert mit der Selbstsicherheit im Umgang mit rationaler Antibiotikaverordnung? : Ergebnisse der MR2-Studien an deutschen Kliniken.

BACKGROUND: Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area. OBJECTIVE: This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge. METHODS: In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ2-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items. RESULTS: The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics. CONCLUSION: Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

[Out-of-hospital airway management with a laryngeal tube or endotracheal intubation for out-of-hospital cardiac arrest : Influence on in-hospital mortality]. / Präklinisches Atemwegsmanagement mit Larynxtubus oder Endotrachealtubus bei präklinischem Herz-Kreislauf-Stillstand : Einfluss auf die Krankenhausmortalität.

BACKGROUND: Endotracheal (ET) intubation has been the gold standard in out-of-hospital airway management for a long time. Recent guidelines suggest an alternative airway management with supraglottic airway devices like the laryngeal tube (LT) especially for less experienced rescue personnel. However, scientific evidence on the prognostic impact of the laryngeal tube in the setting of cardiopulmonary resuscitation is limited. METHODS: We aimed to compare mortality outcomes in out-of-hospital cardiac arrest (OHCA) patients after preclinically initiated airway management with either ET or LT in a propensity score matched, single-center retrospective analysis. RESULTS: A total of 208 patients with OHCA were resuscitated and intubated with either ET (n = 160; 77%) or LT (n = 48; 23%) in the urban area of Frankfurt am Main, Germany, and treated thereafter on the intensive care unit of the University Hospital Frankfurt from 2006-2014. In-hospital mortality was 84% versus 85% in the ET and LT group (p = 0.86). No difference regarding in-hospital mortality has been observed between the two airway management techniques in univariate as well as in multivariate mortality analysis (HR = 0.98, 95% confidence interval [CI] 0.69-1.39; p = 0.92; adjusted HR = 1.01, 95% CI 0.76-1.56; p = 0.62). To adjust for potential confounders, propensity score matching was additionally performed resulting in a cohort of 120 matched patients in a 3:1 ratio (ET:LT). Again, survival to hospital discharge was comparable between the two patient groups (propensity-adjusted HR = 0.99, 95% CI 0.65-1.51, p = 0.97). Further, preclinical airway management with LT or ET showed no difference in mortality within first 24 h (propensity-adjusted HR = 1.02; 95% CI 0.44-2.36; p = 0.96). CONCLUSION: Preclinical airway management with LT shows similar mortality outcomes in direct comparison to intubation with ET in OHCA patients. Further randomized studies are warranted.

[Valvular heart disease: anesthesia in non-cardiac surgery]. / Herzklappenerkrankungen : Anästhesie bei nichtkardiochirurgischen Eingriffen.

The probability of treating patients with valvular heart disease during non-cardiac surgery increases with the age of the patient. The prevalence of valvular heart disease is approximately 2.5% and increases further in the patient group aged over 75 years old. Patients with valvular heart disease undergoing non-cardiac surgery have an increased perioperative cardiovascular risk depending on the severity of the disease. Knowledge of the hemodynamic alterations and compensation mechanisms which accompany diseases of the valve apparatus is essential for a suitable treatment of patients with such pre-existing diseases. The most common valvular heart diseases lead to volume (mitral valve insufficiency) or pressure load (aortic stenosis) of the left ventricle and in the case of mitral stenosis to a pressure load on the left atrium. Depending on the underlying disease and the type of surgery planned a corresponding choice of anesthesia procedure and medication must be made. In the present review article the pathophysiology of the relevant valvular heart diseases and the implications for perioperative anesthesia management will be presented. An individually tailored extended perioperative monitoring allows hemodynamic alterations to be rapidly recognized and adequately treated.

[Preoperative evaluation and risk estimation in thoracic surgery]. / Präoperative Evaluation und Risikoeinschätzung in der Thoraxchirurgie.

Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.