Search PubMed⌕ Search

Biomedical subjects

C Spies

Publications and source records attributed to C Spies.

At least 19 recordsLinked to original sources
PubMed2007

[Analysis of personnel costs after reorganization of intensive care using calculated diagnosis-related groups comparative data. An investigation at the Charité Berlin].

BACKGROUND: In an extensive project intensive care units (ICUs) of the Charité University Hospital were reorganized. The aim of this investigation was to determine if staff costs after this reorganization are financed by modular profits of diagnosis-related groups (DRGs). METHODS: Staff costs of all non-pediatric intensive care units, including ICUs, intermediate care units and post-anaesthesia care units (PACUs) in the Charité University Hospital were compared with the modular profits of all DRGs of patients older than 14 years in 2005. These DRGs were converted into the German refined DRG (GDRG) system 4.0 from 2006 with calculations based on actual income for medical doctors and nurses in 2006. Due to changed wage agreements for the incomes of physicians in 2006 there was an increase of costs. For the other professional groups an increase in income is expected, which cannot be estimated at present. RESULTS: The calculation revealed that staff costs of the ICUs at the Charité University Hospital based on a current German mean base rate of 2,836 EUR were 4.2% above the modular profits of the DRGs. As a result of a structural reorganization of the ICUs, the costs of staff could be adapted to the modular profits. Under the conditions of the actual reduced base rate of Berlin of 2,955 EUR the costs and profits were nearly equal. As the financial impact of the reorganization of the ICUs will take full effect in the coming years, it can be anticipated that with an expected base rate of 2,949 EUR in 2010 the intensive care medicine of a University hospital in Germany can become profitable. DISCUSSION: The spectrum of intensive care medicine at the Charité University Hospital covers the maximum range of operative and non-operative medicine. After an extensive reorganization of the ICUs under the aspect of staff costs, intensive care medicine can become profitable under the 4.0 G-DRG system. With consequent reorganization the cost efficiency of staff can be optimized, particularly in the setting of high-end intensive care medicine.

Adolescent↗
PubMed2006

Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey.

BACKGROUND: In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. METHODS: A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. RESULTS: Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. CONCLUSION: Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.

Blood Transfusion↗
PubMed2006

Psychomotor dysfunction after remifentanil/propofol anaesthesia.

BACKGROUND AND OBJECTIVES: Early recovery after anaesthesia is gaining importance in fast track management. The aim of this study was to quantify psychomotor recovery within the first 24 h after propofol/remifentanil anaesthesia using the Short Performance Test (Syndrom Kurztest (SKT)), consisting of nine subtests. The hypothesis was that psychomotor performance remains reduced 24 h after anaesthesia. METHODS: Thirty-seven patients scheduled for elective surgery took part in the study. The SKT was performed on the day before general anaesthesia (T0), 10, 30, 90 min and 24 h after extubation (T1). Parallel versions were used to minimize learning effects. Anaesthesia was introduced and maintained with remifentanil/propofol as a target controlled infusion. Propofol plasma concentration was measured 10 and 90 min after extubation. Perioperative pain management included novaminsulfon and piritramide. RESULTS: Up till 90 min after surgery and anaesthesia, psychomotor performances were significantly reduced as the lower test results in all SKT subtests indicated (P < or = 0.007 vs. baseline T0). In the three memory subtests (ST 2, ST 8 and ST 9), psychomotor performance was still reduced on the first postoperative day (P < or = 0.005; T1 vs. T0). There was no correlation between propofol plasma concentration and the psychometric test results. CONCLUSIONS: Propofol/remifentanil-based target controlled general anaesthesia for surgery is associated with a reduced psychomotor function up to the first postoperative day. Further studies are needed to confirm the usefulness of the SKT in the perioperative period and to clarify which components in the perioperative period are responsible for a lower performance in the SKT.

Adult↗
PubMed2006

Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries.

BACKGROUND: For colorectal surgery, evidence suggests that optimal management includes: no pre-operative fasting, a thoracic epidural analgesia continued for 2 days post-operatively, and avoidance of fluid overload. In addition, no long-acting benzodiazepines on the day of surgery and use of short-acting anaesthetic medication may be beneficial. We examined whether these strategies have been adopted in five northern-European countries. METHODS: In 2003, a questionnaire concerning peri-operative anaesthetic routines in elective, open colonic cancer resection was sent to the chief anaesthesiologist in 258 digestive surgical centres in Scotland, the Netherlands, Denmark, Sweden and Norway. RESULTS: The response rate was 74% (n = 191). Although periods of pre-operative fasting up to 48 h were reported, most (> 85%) responders in all countries declared to adhere to guidelines for pre-operative fasting and oral clear liquids were permitted until 2-3 h before anaesthesia. Solid food was permitted up to 6-8 h prior to anaesthesia. In all countries more than 85% of the responders indicated that epidural anaesthesia was routinely used. Except for Denmark, long-acting benzodiazepines were still widely used. Short-acting anaesthetics were used in all countries except Scotland where isoflurane is the anaesthetic of choice. With the exception of Denmark, intravenous fluids were used unrestrictedly. CONCLUSION: In northern Europe, most anaesthesiologists adhere to evidence-based optimal management strategies on pre-operative fasting, thoracic epidurals and short-acting anaesthetics. However, premedication with longer-acting agents is still common. Avoidance of fluid overload has not yet found its way into daily practice. This may leave patients undergoing elective colonic surgery at risk of oversedation and excessive fluid administration with potential adverse effects on surgical outcome.

Anesthesia↗
PubMed2006

Development and first validation of the shared decision-making questionnaire (SDM-Q).

OBJECTIVE: Due to a lack of valid German instruments measuring shared decision-making (SDM), a theory-driven questionnaire (SDM-Q) to measure the process of SDM was developed and validated. METHODS: As a theoretical basis steps of the SDM process were defined in an expert panel. Item formulation was then conducted according to the Delphi method. For the first validation on a mixed sample Rasch analysis was used to eliminate items not fitting the construct thus receiving a unidimensional scale. RESULTS: After eliminating 4 items the remaining 11 form a unidimensional scale with an acceptable reliability for person measures (0.77) and very good reliability for item difficulties (0.95). Analysis of subgroups revealed a different use of items in different conditions. Furthermore the scale showed high ceiling effects. CONCLUSION: A new theory-driven instrument to measure the process of SDM has been developed and validated by use of a rigorous method revealing first promising results. Yet the ceiling effects require the addition of more discriminating items, and the different use of items in different conditions demands an in depth analysis. PRACTICE IMPLICATIONS: While the concept of SDM is constantly receiving more attention in medical practice, its valid and reliable measurement remains challenging.

Decision Making↗
PubMed2006

ESPEN Guidelines on Enteral Nutrition: Intensive care.

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

APACHE↗
PubMed2006

[The role of anesthesiology in fast track concepts in colonic surgery].

In the present study the "fast-track rehabilitation" protocol of the Charité university hospital for patients undergoing elective colonic resection is described. The underlying principles, clinical pathways and outcome data from 208 patients are shown. Particularly anesthesiological aspects of this multimodal approach, such as modified preoperative and postoperative fluid management, changed guidelines for preoperative fasting, effective analgetic therapy using epidural analgesia and avoiding high systemic doses of opioids, use of short-acting anesthetic agents, and maintenance of normothermia as well as normovolemia are presented and discussed. In comparison to outcome data before "fast-track rehabilitation" was established, the duration of postoperative hospital stay has been reduced from 12 to 5 days, the number of general complications (pneumonia, duodenal ulcer bleeding, urinary tract infection, cerebral, cardiac and renal dysfunction) decreased from 20% to 7%, whereas surgical complications remained constant at 17% (8% wound infections, 3% anastomotic insufficiency).

Analgesia, Epidural↗
PubMed2006

[Current level of patients' knowledge of anaesthesiology].

The anaesthesiologist's competence in anaesthesia, intensive care medicine, pain therapy and emergency medicine is accepted throughout the medical society. Nevertheless, during the last decades patient surveys demonstrated a considerable lack of information of the responsibility of our work. By continuous education and information anaesthesiologists have aimed to improve the information and decision-making process for the patient. This multicentre trial was designed to investigate the current public view on our profession in seven German hospitals. In-hospital patients were asked to fill out a standardised questionnaire prior to the anaesthesia premedication visit and a total of 692 questionnaires (77%) were analysed. Results demonstrated an increased level of knowledge for anaesthesia (>95%), intensive care medicine (74%), and pain therapy (50% acute pain; 32% severe pain). In the case of emergency medicine (10%) the in-hospital and out-of-hospital responsibilities were not clear among patients. We conclude that the continuous distribution of information in recent years has contributed to improving patients' knowledge on interdisciplinary responsibilities. Future efforts should focus on the gaps in patient's knowledge to allow the patient to ask the right questions necessary for decision-making.

Adult↗
PubMed2006

[Alcohol use disorder: risks in anesthesia and intensive care medicine].

Approximately 20% of medical and surgical patients in hospital have an alcohol use disorder (AUD). Diagnosis of chronic alcohol abuse is performed by specific medical history, examination and validated tests. Biomarkers are a means of diagnosing chronic alcoholism in sedated, intubated and emergency patients. Chronic alcohol consumption damages the central nervous and cardiovascular system, the liver and the immune system. In medical ICUs more than 50% of liver injuries and chronic pancreatitis are due to chronic alcohol abuse. The alcohol withdrawal syndrome is emerging in 25% of AUD patients in intensive care after reduction of sedative drugs. Long term alcohol abuse also leads to cardiac arrhythmias, dilatative cardiomyopathy and hypotonic circulatory dysregulation. Bleeding complications are two-fold increased during and after surgery. Immune suppression results in an increased incidence of infectious complications like pneumonia, wound infection and urinary tract infection. In particular, septic encephalopathy is often misinterpreted as alcohol withdrawal syndrome. Due to the fact that AUD patients show a two to five-fold higher rate of postoperative complications they require increased attention to avoid latency of treatment and the development of multiple organ failure. Prophylaxis in terms of drug therapy or abstinence intervals and brief intervention strategies can help to prevent or ease some of these complications and can decrease the rate of long-term injuries.

Alcohol-Induced Disorders↗
PubMed2006

[Effects of a shared decision making model in psychiatric and neurologic practice].

Involving patients in medical decisions is increasingly being advocated in medical fields other than psychiatry and neurology. A model of shared decision making might prove to be an ideal way of bridging the gap between patient-centred and evidence-based medicine. This report provides a survey of this shared decision making model and a discussion of its implications in the fields of mental health and neurology.

Adaptation, Psychological↗
PubMed2006

[Pain therapy in addicted patients].

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.

Acupuncture Therapy↗
PubMed2006

[The influence of intraoperative fluid therapy on the postoperative outcome in "fast track" colon surgery].

OBJECTIVE: To evaluate the association between the intraoperative and postoperative application of different quantities of fluids and the incidence of postoperative complications after "fast-track"-colonic surgery. METHODS: We performed a retrospective analysis of 136 patients undergoing elective "fast-track" colonic surgery (sigma resection and right hemicolectomy). Data collection in regard of fluid administration during surgery and in the post anaesthesia care unit (PACU) was based on anaesthesia charts and a prospectively generated surgery database. Classification into three volume groups (up to 3500 ml = group 1, 3500 - 5500 ml = group 2, more than 5500 ml = group 3). Basic patient characteristics, pre-existing conditions, type and duration of surgery and anastomoses were documented. We analysed the incidence of postoperative complications such as wound infections, anastomotic leak, bleeding, bowel obstruction, cardiovascular failure, hypertension, pulmonary failure, pneumonia, renal failure, urinary tract infection, neurological and psychiatric complications in the different volume groups. RESULTS: 115 patients were infused with up to 3500 mLs of fluids, 19 patients received more than 3500 mLs, two patients were infused with 6000 ml and 7500 mLs, respectively. This was in median 36 ml/kg in the restrictive and 53 ml/kg in the higher volume groups (group 2 and 3 together), respectively. The duration of surgery and anaesthesia was significantly different between both fluid groups (p = 0,023). In a logistic regression model only intraoperative blood loss was independently associated with the volume of infused fluid (OR 0,393, 95 % CI 1.028 - 2.306, p < 0.01). The rate of postoperative complications was not different between groups (p = 0,228). CONCLUSION: The incidence of postoperative complications was not different between patients who were infused 36 ml/kg or 53 ml/kg of fluids during surgery and post anaesthesia care unit stay.

Aged↗
PubMed2006

[Bleeding after cardiac surgery: the role of recombinant factor VIIa].

Cardiac surgery carries a remarkable risk of blood loss requiring transfusion of blood products. Moreover, severe bleeding necessitating reoperation occurs in 3-5% of patients according to international studies. These patients face a significantly higher morbidity and mortality. This underscores the need for a safe and effective haemostatic therapy, which may significantly improve the outcome. Recombinant activated factor VII is approved for haemophiliacs with inhibitors and patients with thrombasthenia Glanzmann and factor VII deficiency. In the proceeding years a series of articles has been published reporting the successful and safe therapy of refractory bleeding after cardiac surgery. This review focuses at presenting the pathophysiological alterations of the haemostatic system related to the cardiopulmonary bypass. These alterations are thought to explain the high risk of bleeding after cardiopulmonary bypass. Furthermore, the use of rFVIIa in paediatric and adult cardiac surgery is reviewed and critically discussed.

Blood Coagulation↗
PubMed2005

[Quality assurance of haemotherapy in anaesthesia. Auswertung eines 3-jahrigen Erfahrungszeitraums].

BACKGROUND: The measures for quality assurance in haemotherapy developed at the Charite Campus Mitte according to the transfusion law of 1998 are introduced and discussed. METHODS: In a 3-year study period the submission of transfusion documentation and the expiration of blood products were compared to the year 2001. The potentials for improvement for 2001-2003 were compared based on evaluation of the self-inspection documentation of the transfusion clinics. RESULTS: The submission rate for the transfusion documentation increased from 90% in 2001 to 98.3% in 2002 and 2003. The expiration of blood products decreased from 5.1% in 2001 to 1.7% in 2003 resulting in a cost reduction from 140,000 Euro to 50,000 Euro. Continuous need for improvement was found for the prescribed annual further education of staff on quality management. CONCLUSIONS: The self-inspection procedure in transfusion clinics still revealed potential for improvement, although documentation of transfusions were improved and the expiration of blood products and the resulting costs were substantially reduced.

Anesthesia↗
PubMed2005

[Intrathecal misplacement of an interscalene plexus catheter].

For perioperative anesthesia in a case of shoulder arthroscopy, a continuous interscalene plexus block according to Meier was performed in a 51-year-old female patient. The catheter was placed after stimulator-assisted punction and application of a local anesthetic. A few minutes after a further dose of local anesthetic was given via the catheter, the patient had to be intubated and ventilated with signs of total spinal anesthesia. The cervical CT showed the intrathecal displacement of the catheter, reaching the spinal canal near the root of the 7th spinal nerve. Blind advancement and deep placement increase the risk of an abnormal catheter position. Intraspinal misplacement should be reliably excluded.

Anesthesia, Spinal↗
PubMed2005

[Clinical pathway "laparoscopic prostatectomy". Analysis of anesthesiological procedures in a randomized study].

METHODS: In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure. RESULTS: There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs. CONCLUSION: Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.

Aged↗