, Volume 62, Issue 5, pp 365-379
Date: 10 May 2013

Zur präoperativen Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen

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Zusammenfassung

Hintergrund

Die Indikationsstellung diagnostischer Verfahren zur präoperativen Evaluation wurde in aktuellen, interdisziplinären Fachempfehlungen kritisch hinterfragt, und es wurden neue Empfehlungen ausgesprochen. Unklar ist, wie in den ersten Monaten nach Publikation die diesbezügliche Praxis bei den klinisch tätigen Anästhesisten aussah.

Methode

Drei Monate nach Veröffentlichung wurden alle in einer hessischen Klinik angestellten Anästhesisten für eine Datenerhebung durch Onlinebefragung (OB) und Interviewbefragung (IB) eingeladen. Es wurden Bekanntheit, Akzeptanz und Umsetzung der Empfehlungen in die tägliche Praxis untersucht. Ferner wurden allgemein und anhand von 2 Fallbeispielen die Indikationen gängiger Diagnostikverfahren untersucht und hinsichtlich der Übereinstimmung mit den Empfehlungen verglichen.

Ergebnisse

An der Studie nahmen 396 der kontaktierten Ärzte (29 %) teil. Es gaben 30 % der Antwortenden an, mit der Empfehlung vertraut zu sein, 34 % äußerten Teilwissen, 20 % nur Kenntnis der Veröffentlichung, und für 16 % war alles unbekannt. In der IB waren die Kenntnisse noch geringer. Für zumindest überwiegend sinnvoll hielten 90 % der Ärzte die Empfehlung. Die Bereitschaft zur Umsetzung wurde von fast der Hälfte erklärt. Für das 12-Kanal-EKG und die Thoraxröntgenuntersuchung sind hausinterne Standards die häufigste Indikation. Demgegenüber werden die Echokardiographie, die Lungenfunktionsuntersuchung und die Belastungselektrokardiographie überwiegend nach eigener Einschätzung indiziert; hierbei korrelierten die klinischen Begründungen häufig nicht mit den Empfehlungen. Bei den Fallbeispielen wies die Indikationsstellung der diagnostischen Maßnahmen in der IB meist ein größeres Ausmaß an Konformität mit den Empfehlungen auf als bei der OB.

Schlussfolgerung

Entsprechend dem hohen Stellenwert hausinterner Standards für die Indikationsstellung diagnostischer Verfahren erscheint die Erstellung von empfehlungskonformen eigenen Standards als sinnvolle Möglichkeit, die Implementierung der Empfehlungen zu fördern.

Abstract

Background

The German Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine and Surgery have recently published for the first time joint recommendations for the evaluation of adult patients prior to elective non-cardiac surgery. In these recommendations indications for preoperative diagnostic procedures were critically revised and updated. It was unclear to what extent these recommendations were known among German anesthesiologists, how the recommendations were perceived and to what extent they were put into practice. The indications of five common diagnostic procedures in the context of the preoperative evaluation were also unknown.

Methods

Three months after publication of the recommendations, all anesthesiologists employed at hospitals in the state of Hessen were requested to take part in an online survey (OS). In the first part of the OS participants were asked about familiarity with the recommendations, opinions concerning the utility of the recommendations and to what extent they were implemented. In the second part of the OS participants were questioned in general and in the context of two common case scenarios about indications for electrocardiograms (ECG), chest radiographs (chest x-ray), echocardiograms, spirometry and extended cardiac diagnostics, such as stress ECG. In addition, participants of the OS were requested to take part in an interview survey (IS) addressing the same topics. The purpose of the IS was to detect any bias caused by the anonymous character of the OS which could lead to an overestimated self-assessment. Answers of the IS were not compared to the results of the corresponding answers given online by the same anesthesiologist but only analyzed together with the other results of the IS for comparison with the results of the OS.

Results

Of the contacted anesthesiologists 396 (29 %) took part in the OS of which 100 took part in the IS. According to the OS 30 % were familiar and 34 % were partially familiar with the recommendations, 20 % just knew that recommendations had been published and 16 % did not even know about the publication. The corresponding results of the IS were 16 %, 36 %, 28 % and 20 %, respectively. Of the participants 90 % (OS) and 89 % (IS) considered the recommendations at least to be predominantly reasonable and useful and 66 % (OS) of the participants tried to implement or at least to partially implement the recommendations (IS only 33 %).

Concerning the indications for the different diagnostic procedures, the results of the OS showed that hospital guidelines (44 %) and patient age (32 %) were the most frequent indications for a preoperative ECG. Hospital guidelines (40 %) and own judgement (39 %) were the most common indications for a preoperative chest x-ray and patient age still accounted for 18 % of the indications. In contrast, echocardiography (67 %), spirometry (61 %) and extended cardiac diagnostics (70 %) were primarily indicated based on own judgement. However, reasons given in this context were frequently (77 %) not in agreement with the recommendations.

Comparing the results of the OS to those of the IS with respect to the indications of the different diagnostic procedures for the common case scenarios showed a varying degree of consistency with the recommendations. In both cases responses to the IS concerning the indications for the different diagnostic procedures were mostly in accordance with the recommendations compared to answers obtained in the OS. Indications for the chest x-ray showed the worst degree of consistency with the recommendations.

Conclusions

Corresponding to the high significance of local standards for the decision of indicating preoperative diagnostic procedures, the development of local standards that are in agreement with the recommendations seems to be a reasonable way to facilitate the implementation of the recommendations.