Der Anaesthesist
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In 2015 practice management guidelines on prehospital emergency anesthesia in adults were published in Germany. The aim of the present study was to evaluate whether emergency physicians follow these guidelines in daily practice and to assess their level of experience with the use of anesthetic agents. ⋯ The results of this survey demonstrate that clinical practice of emergency physicians is in high accordance with the recommendations named in the guidelines for prehospital emergency anesthesia in adults (except for cardiac patients and time of preoxygenation). With respect to the lower levels of experience of non-anesthetists in the use of anesthetic drugs, specific training concepts may help to further improve the quality of preclinical emergency care.
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Antibiotic stewardship (ABS) comprises a bundle of different interventions to improve anti-infective treatment in a hospital setting. An important component of ABS interventions is the interdisciplinary approach to infection management. Besides improving infrastructural aspects on a hospital level, including surveillance of the use of anti-infective agents and nosocomial infections, collation and interpretation of statistics on resistance and formulation of local treatment guidelines, ABS teams go to the wards and advise treating physicians on antibiotic therapy. ⋯ An important overall objective of ABS is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. A number of studies have shown that this goal can be achieved in different clinical settings without negatively affecting patient outcome. The strategies of ABS can also be applied with no problems to critically ill patients on the intensive care unit.
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Acute pain management is an interprofessional and interdisciplinary task and requires a good and trustful cooperation between stakeholders. Despite provisions in Germany according to which medical treatment can only be rendered by a formally qualified physician ("Arztvorbehalt"), a physician does not have to carry out every medical activity in person. Under certain conditions, some medical activities can be delegated to medical auxiliary personnel but they need to be (1) instructed, (2) supervised and (3) checked by the physician himself; however, medical history, diagnostic assessment and evaluation, indications, therapy planning (e.g. selection, dosage), therapeutic decisions (e. g. modification or termination of therapy) and obtaining informed consent cannot be delegated. ⋯ The use of standards of care improves treatment quality but like any medical treatment it must be based on the physician's individual assessment and indications for each patient and requires personal contact between physician and patient. Delegation on the ward and in acute pain therapy requires the authorization of the delegator to give instructions in the respective setting. The transfer of non-delegable duties to non-medical personnel is regarded as medical malpractice.
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Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. ⋯ The conformity to the algorithm of over 90% indicates a good training level of the participants concerning the difficult airway algorithm. In the observed sample flexible intubation endoscopy tended to be of high significance even in the unanticipated difficult airway. Cricothyrotomy was performed faster surgically than by the use of the transtracheal puncture approach, while no differences between junior and senior anesthetists were observed. For the successful management of an unexpected difficult airway, specific training of these special and rare events is crucial. A standardized provision of special airway instruments stored in a special trolley and frequent application of this trolley in the clinical routine is recommended.