Download PDF
Thorac Cardiovasc Surg 2024; 72(01): 002-010
DOI: 10.1055/s-0043-1764230
Original Cardiovascular

Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients

Thomas Simon Zajonz
1   Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
,
Marit Habicher
1   Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
,
Andreas Böning
2   Department of Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
3   Department of Adult and Pediatric Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
,
Matthias Heringlake
4   Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center Mecklenburg, Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
,
Jörg Ender
5   Department of Anaesthesiology and Intensive Care Medicine, Leipzig Heart Centre University Hospital, Heart Center Leipzig, Leipzig, Sachsen, Germany
,
Andreas Markewitz
6   Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, Berlin, Germany
,
Florian Brenck   *
1   Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
,
Michael Sander   *
1   Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
› Author Affiliations
› Further Information
    Permissions and Reprints All articles of this category

Abstract

Background The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs).

Methods An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008.

Results A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%).

Conclusion Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

Keywords

cardiac - intensive care - postoperative care - guidelines

Ethical Approval Statement

Ethical approval for this study was not required as no animals or patients are involved.


* Both authors contributed equally to the manuscript.




Publication History

Received: 19 November 2022

Accepted: 21 January 2023

Article published online:
09 March 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kastrup M, Carl M, Spies C, Sander M, Markewitz A, Schirmer U. Clinical impact of the publication of S3 guidelines for intensive care in cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2013; 57 (02) 206-213
    CrossrefPubMedGoogle Scholar
  • 2 Pinho-Gomes A-C, Azevedo L, Ahn J-M. et al. Compliance with guideline-directed medical therapy in contemporary coronary revascularization trials. J Am Coll Cardiol 2018; 71 (06) 591-602
    CrossrefPubMedGoogle Scholar
  • 3 Menger J, Edlinger-Stanger M, Dworschak M, Steinlechner B. Postoperative management of patients undergoing cardiac surgery in Austria : a national survey on current clinical practice in hemodynamic monitoring and postoperative management. Wien Klin Wochenschr 2018; 130 (23–24): 716-721
    CrossrefPubMedGoogle Scholar
  • 4 Funcke S, Sander M, Goepfert MS. et al; ICU-CardioMan Investigators. Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan study. Ann Intensive Care 2016; 6 (01) 49
    CrossrefPubMedGoogle Scholar
  • 5 Armstrong JJ, Goldfarb AM, Instrum RS, MacDermid JC. Improvement evident but still necessary in clinical practice guideline quality: a systematic review. J Clin Epidemiol 2017; 81: 13-21
    CrossrefPubMedGoogle Scholar
  • 6 Habicher M, Zajonz T, Bauer A. et al. S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf. 2018. Accessed April 20, 2021 at: https://www.awmf.org/uploads/tx_szleitlinien/001-016l_S3_Intensivmedizinische_Versorgung-Haemodynamisches-Monitoring_2018-06.pdf
    PubMed
  • 7 AWMF. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF)-Ständige Kommission Leitlinien. 2020. Accessed August 16, 2022 at: http://www.awmf.org/leitlinien/awmf-regelwerk.html
    PubMed
  • 8 Muche-Borowski C, Nothacker M, Kopp I. Guideline Implementation. Bundesgesundheitsbl 2015; 12 (58) 32-37
    PubMedGoogle Scholar
  • 9 Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318 (7182): 527-530
    CrossrefPubMedGoogle Scholar
  • 10 Goorts K, Dizon J, Milanese S. The effectiveness of implementation strategies for promoting evidence informed interventions in allied healthcare: a systematic review. BMC Health Serv Res 2021; 21 (01) 241
    CrossrefPubMedGoogle Scholar
  • 11 Collaborative Study Group on Perioperative ScvO2 Monitoring. Multicentre study on peri- and postoperative central venous oxygen saturation in high-risk surgical patients. Crit Care 2006; 10 (06) R158
    CrossrefPubMedGoogle Scholar
  • 12 Balzer F, Sander M, Simon M. et al. High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study. Crit Care 2015; 19 (01) 168
    CrossrefPubMedGoogle Scholar
  • 13 Laine GA, Hu BY, Wang S, Thomas Solis R, Reul Jr GJ. Isolated high lactate or low central venous oxygen saturation after cardiac surgery and association with outcome. J Cardiothorac Vasc Anesth 2013; 27 (06) 1271-1276
    CrossrefPubMedGoogle Scholar
  • 14 American Society of Anesthesiologists. (2020) Standards for basic anesthetic monitoring. Accessed May 21, 2021 at: https://www.asahq.org/standards-and-guidelines/standards-for-basic-anesthetic-monitoring
    PubMed
  • 15 College of Intensive Care Medicineof Australia and New Zealand. (2011) MINIMUM STANDARDS FOR INTENSIVE CARE UNITS. Accessed May 22, 2021 at: https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-1-Minimum-Standards-for-Intensive-Care-Units.pdf
    PubMed
  • 16 Sorgatz H, Hisom A. Resolutions, Recommendations, Agreements: A Contribution to Quality Assurance in Anesthesiology. Ebelsbach: Aktiv Druck & Verlag GmbH; 2011: 5
    Google Scholar
  • 17 The Faculty of Intensive Care Medicine. Guidelines for the Provision of Intensive Care Services V2. 2019. Accessed May 22, 2021 at: https://www.ficm.ac.uk/sites/default/files/gpics-v2.pdf
    PubMed
  • 18 Kurtz P, Gaspard N, Wahl AS. et al. Continuous electroencephalography in a surgical intensive care unit. Intensive Care Med 2014; 40 (02) 228-234
    CrossrefPubMedGoogle Scholar
  • 19 Herman ST, Abend NS, Bleck TP. et al; Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol 2015; 32 (02) 87-95
    CrossrefPubMedGoogle Scholar
  • 20 Hilkman DMW, van Mook WNKA, van Kranen-Mastenbroek VHJM. Continuous electroencephalographic-monitoring in the ICU: an overview of current strengths and future challenges. Curr Opin Anaesthesiol 2017; 30 (02) 192-199
    CrossrefPubMedGoogle Scholar
  • 21 Hirsch LJ. Continuous EEG monitoring in the intensive care unit: an overview. J Clin Neurophysiol 2004; 21 (05) 332-340
    PubMedGoogle Scholar
  • 22 Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M. Neurointensive Care Section of the European Society of Intensive Care Medicine. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39 (08) 1337-1351
    CrossrefPubMedGoogle Scholar
  • 23 Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2013; 110 (04) 510-517
    CrossrefPubMedGoogle Scholar
  • 24 Xu J-Y, Chen Q-H, Liu S-Q. et al. The effect of early goal-directed therapy on outcome in adult severe sepsis and septic shock patients: a meta-analysis of randomized clinical trials. Anesth Analg 2016; 123 (02) 371-381
    CrossrefPubMedGoogle Scholar
  • 25 Sivayoham N, Rhodes A, Jaiganesh T, van Zyl Smit N, Elkhodhair S, Krishnanandan S. Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock : a 4-year observational cohort study. Eur J Emerg Med 2012; 19 (04) 235-240
    CrossrefPubMedGoogle Scholar
  • 26 Levitov A, Frankel HL, Blaivas M. et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part II: cardiac ultrasonography. Crit Care Med 2016; 44 (06) 1206-1227
    CrossrefPubMedGoogle Scholar
  • 27 Vieillard-Baron A, Millington SJ, Sanfilippo F. et al. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med 2019; 45 (06) 770-788
    CrossrefPubMedGoogle Scholar
  • 28 Vezzani A, Manca T, Brusasco C. et al. Diagnostic value of chest ultrasound after cardiac surgery: a comparison with chest X-ray and auscultation. J Cardiothorac Vasc Anesth 2014; 28 (06) 1527-1532
    CrossrefPubMedGoogle Scholar
  • 29 Pagano D, Kappetein AP, Sousa-Uva M. et al; European Association for Cardio-Thoracic Surgery (EACTS) and the EACTS Quality Improvement Programme. EACTS clinical statement: guidance for the provision of adult cardiac surgery. Eur J Cardiothorac Surg 2016; 50 (06) 1006-1009
    CrossrefPubMedGoogle Scholar
  • 30 Marx G, Schindler AW, Mosch C. et al. Intravascular volume therapy in adults: guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33 (07) 488-521
    CrossrefPubMedGoogle Scholar
  • 31 Martin C, Jacob M, Vicaut E, Guidet B, Van Aken H, Kurz A. Effect of waxy maize-derived hydroxyethyl starch 130/0.4 on renal function in surgical patients. Anesthesiology 2013; 118 (02) 387-394
    CrossrefPubMedGoogle Scholar
  • 32 Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S. CHEST Management Committee. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg 2012; 114 (01) 159-169
    CrossrefPubMedGoogle Scholar
  • 33 Annane D, Siami S, Jaber S. et al; CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013; 310 (17) 1809-1817
    CrossrefPubMedGoogle Scholar
  • 34 Rhodes A, Evans LE, Alhazzani W. et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017; 45 (03) 486-552
    CrossrefPubMedGoogle Scholar
  • 35 Reinhart K, Perner A, Sprung CL. et al; European Society of Intensive Care Medicine. Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med 2012; 38 (03) 368-383
    CrossrefPubMedGoogle Scholar
  • 36 Moeller C, Fleischmann C, Thomas-Rueddel D. et al. How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin. J Crit Care 2016; 35: 75-83
    CrossrefPubMedGoogle Scholar
  • 37 Semler MW, Self WH, Wanderer JP. et al; SMART Investigators and the Pragmatic Critical Care Research Group. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018; 378 (09) 829-839
    CrossrefPubMedGoogle Scholar
  • 38 Finfer S, Micallef S, Hammond N. et al; PLUS Study Investigators and the Australian New Zealand Intensive Care Society Clinical Trials Group. Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med 2022; 386 (09) 815-826
    CrossrefPubMedGoogle Scholar
  • 39 Antequera Martín AM, Barea Mendoza JA, Muriel A. et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev 2019; 7 (07) CD012247
    PubMedGoogle Scholar
  • 40 De Backer D, Vincent J-L. Should we measure the central venous pressure to guide fluid management? Ten answers to 10 questions. Crit Care 2018; 22 (01) 43
    CrossrefPubMedGoogle Scholar
  • 41 Maharaj R, Metaxa V. Levosimendan and mortality after coronary revascularisation: a meta-analysis of randomised controlled trials. Crit Care 2011; 15 (03) R140
    CrossrefPubMedGoogle Scholar
  • 42 Harrison RW, Hasselblad V, Mehta RH, Levin R, Harrington RA, Alexander JH. Effect of levosimendan on survival and adverse events after cardiac surgery: a meta-analysis. J Cardiothorac Vasc Anesth 2013; 27 (06) 1224-1232
    CrossrefPubMedGoogle Scholar
  • 43 Wang B, He X, Gong Y, Cheng B. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery: an update meta-analysis and trial sequential analysis. BioMed Res Int 2018; 2018: 7563083
    PubMedGoogle Scholar
  • 44 Mehta RH, Leimberger JD, van Diepen S. et al; LEVO-CTS Investigators. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery. N Engl J Med 2017; 376 (21) 2032-2042
    CrossrefPubMedGoogle Scholar
  • 45 Cholley B, Caruba T, Grosjean S. et al; -. Effect of levosimendan on low cardiac output syndrome in patients with low ejection fraction undergoing coronary artery bypass grafting with cardiopulmonary bypass: the LICORN randomized clinical trial. JAMA 2017; 318 (06) 548-556
    CrossrefPubMedGoogle Scholar
  • 46 Landoni G, Lomivorotov VV, Alvaro G. et al; CHEETAH Study Group. Levosimendan for hemodynamic support after cardiac surgery. N Engl J Med 2017; 376 (21) 2021-2031
    CrossrefPubMedGoogle Scholar
  • 47 Denissen JJA, Neumann L, van Zalk M. How the internet is changing the implementation of traditional research methods, people's daily lives, and the way in which developmental scientists conduct research. Int J Behav Dev 2010; 34 (06) 564-575
    CrossrefPubMedGoogle Scholar
  • 48 Chung CKE, Poon CCM, Irwin MG. Peri-operative neurological monitoring with electroencephalography and cerebral oximetry: a narrative review. Anaesthesia 2022; 77 (Suppl 1): 113-122
    CrossrefPubMedGoogle Scholar
  • 49 Dillman DA, Smyth JD, Christian LM. . Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method, 4 edition. Aufl. Wiley, s.l.; 2014
  • 50 Leopold H. Rücklauf bei Online Befragungen im Online Access Panel. Zugl.: Gießen, Univ., Diss., 2004. Schriften zur Arbeits-, Betriebs- und Organisationspsychologie, vol 10. Kovač, Hamburg
    PubMedGoogle Scholar
  • 51 Sheehan KB. E-mail Survey Response Rates: A Review. Journal of Computer-Mediated Communication 2001; 6: https://doi.org/10.1111/j.1083-6101.2001.tb00117.x
    CrossrefPubMedGoogle Scholar
  • 52 Patel D, Taljaard M, Yadav K, James D, Perry JJ. Current pCce for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: a national survey. Headache 2022; 62 (04) 512-521
    CrossrefPubMedGoogle Scholar
  • 53 Leslie LL. Are high response rates essential to valid surveys?. Soc Sci Res 1972; 1 (03) 323-334
    CrossrefPubMedGoogle Scholar