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Der Anaesthesist [journal]
- [Specific aspects of anesthesiological management of laser surgery in otorhinolaryngology]. [English Abstract, Journal Article]
- Anaesthesist 2014 Jun; 63(6):519-30.
Transoral laser surgery has become a standard procedure in the treatment of benign and malignant neoplasms of the upper aerodigestive tract. As the laser cuts and coagulates simultaneously, intraoperative bleeding is reduced, thus improving visualization of the operative field. However, the specific risks for patients and personnel that are associated with this technique necessitate strict compliance with safety regulations and precautions. The safe anesthesiological and surgical management of such procedures requires explicit knowledge of the risks inherent to laser use, as well as close communication between surgeon and anesthesiologist throughout all operative and perioperative procedures. Although potentially fatal complications are rare, surgeon and anesthesiologist need to be aware of the dangers at all times and have exact knowledge of emergency measures. The use of suitable laser-resistant endotracheal tubes, total intravenous anesthesia and an optimized breathing gas mixture can contribute to minimize the occurrence of complications in otorhinolaryngology laser surgery.
- [Risk consideration for peridural catheter removal in acute coronary syndrome : Epidural hematoma versus stent thrombosis.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 25.
Perioperative pain therapy using an epidural catheter is the standard operating procedure for numerous surgical interventions. The necessity of initiating anticoagulant therapy in a patient with an epidural catheter requires a careful weighing up between thromboembolic complications and epidural hematoma. The case presented here of a 47-year-old female patient who was operated on for mastectomy with a latissimus dorsi myocutaneous flap demonstrates a possible solution to this dilemma. The patient sustained a perioperative ST elevation myocardial infarction treated with drug-eluting stents while undergoing epidural pain therapy. By using the short-acting antiplatelet drug tirofiban over a time period of 7 days the gap for dual antiplatelet therapy was reduced with the help of specific platelet aggregation assays to a time frame of a few hours to minimize the risk of stent thrombosis. The epidural catheter was removed without complications under consideration of the current recommendations for regional anesthesia and antithrombotic agents.
- [Improvement of emergency physician education through simulator training : Consideration on the basis of the model project "NASimSaar25"] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 24.
Prehospital emergency medicine is a challenge for trainee emergency physicians. Rare injuries and diseases as well as patients in extreme age groups can unexpectedly face emergency physicians. In the regulations on medical education the German Medical Association requires participation in 50 emergency missions under the supervision of an experienced emergency physician. This needs to be improved because on-the-job training does not generally represent the whole spectrum of emergency medicine and a good and structured training under on call conditions is nearly impossible.The subject of the model project described was whether practical training for emergency physicians can be achieved by participation in simulation training instead of real emergency situations.After modification of the Saarland regulations on medical education it was possible to replace up to 25 participations in emergency missions by simulation training. The concept of the course NASimSaar25 requires participants to complete 25 simulator cases in 3 days in small training groups. Emergency situations from all medical disciplines need to be treated. A special focus is on the treatment of life-threatening and rare diseases and injuries. Modern simulators and actors are used. The debriefings are conducted by experienced tutors based on approved principles. Medical contents, learning targets from the field of crew resource management (CRM) and soft skills are discussed in these debriefings.Education in the field of emergency medicine can be improved by simulator-based learning and training. However, practical work under a tutor in real and clinical experience cannot be completely replaced by simulation. Simulator training can only be successful if theoretical knowledge has already been acquired.A simulator-based course concept can result in an improvement of emergency medical education. The model project NASimSaar25 was well received by the target audience and mostly very well evaluated in terms of learning and reality. If this project becomes established the demand on simulation-based training will increase. The training should achieve a consistent standard of quality.
- Nerve localization for peripheral regional anesthesia : Recommendations of the German Society of Anaesthesiology and Intensive Care Medicine. [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul; 63(7):597-602.
The German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) established an expert panel to develop preliminary recommendations for nerve localization in peripheral regional anesthesia. Based on expert knowledge and the relatively limited data, the recommendations state how ultrasound and/or electrical nerve stimulation should be used in daily practice, and where and when local anesthetics should be injected. Moreover, it was defined under which conditions a peripheral nerve block under general anesthesia or deep sedation is applicable.Regarding the use of ultrasound the expert opinion was that out-of-plane and in-plane-techniques can be considered equal with respect to patient safety. Nevertheless, the direct or indirect visualization of the needle tip has to be assured. The injection of local anesthetics has to be visualized. Injections into nerves or those requiring an injection pressure should be avoided. The sole use of electrical nerve stimulation or ultrasound for nerve localization is still a suitable option as well as their combined use. To avoid accidental intraneural needle placement, an electrical current threshold ≥ 0.5 mA should be used. Moreover, it was stated that peripheral nerve blocks or continuous nerve block techniques under sedation or general anesthesia are applicable in adult patients who are unable to tolerate the block being performed in an awake state or have difficulty cooperating.This article is published in English.
- [Uvular edema : Rare complication in anesthesia]. [English Abstract, Journal Article]
- Anaesthesist 2014 Jul; 63(7):574-7.
A uvular edema can be associated with angioedema, urticaria and anaphylaxis. Furthermore, it can be caused by medications, such as angiotensin-converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs and angiotensin II receptor antagonists. Other reasons can be cannabis or cocaine use or a traumatic irritation of the uvula. This article presents the case of a patient who underwent kidney transplantation and developed extensive edema of the uvula that occurred postoperatively after general anaesthesia. The case report describes the diagnosis and therapy of this rare disease.
- [Cardiac arrest in spectators in German football stadiums : Precautionary measures, frequency and short-term outcome.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 23.
Provision of medical care is an important element of safety precautions for visitors of sports arenas. The organizational requirements are especially high if cardiac arrest occurs; how this scenario is managed may thus serve as the ultimate indicator of the quality of stadium medical care. The objectives of this study were to analyze the structures and the resources available for the medical care of spectators in German professional soccer stadiums and to identify the frequency and the primary resuscitation success of cardiac arrest.In 2011 a questionnaire-based survey was performed among the clubs of the first and second German soccer leagues regarding medical care of spectators during the seasons 2008/2009 and 2009/2010. The focus was on the qualifications of emergency teams, the equipment and the incidence of cardiac arrest.A total of 15 stadiums were included (38 %) in the survey. The mean number of physicians and emergency medical technicians on site was 0.6/10,000 seats and 16/10,000 seats, respectively. Of the latter, a mean of 82 % (minimum 20 % and maximum 100 %) had received training with automatic external defibrillators. In 87 % of the stadiums regular advanced life support training (ALS) was required. The mean number of defibrillators per stadium was 2.8/10,000 seats (minimum 1.3 and maximum 3.8) including 1.7 automatic defibrillators (minimum 0.4 and maximum 2.8). For patient transport, a mean of 0.65 ALS ambulance vehicles per 10,000 seats (minimum 0.14 and maximum 1.46) were available on site. In all stadiums staff members were connected via mobile radio communication with the stadium medical control room. A total of 52 cardiac arrests (= 0.25/100,000 spectators) were recorded of which 96 % of the patients were transported to hospitals with spontaneous circulation.Cardiac arrests are not a rare occurrence in German soccer stadiums. The participating stadiums are overall well prepared for such incidents in terms of organization, staff and technology and due to short response times, the resuscitation success by far surpasses that of the standard emergency medical services. These findings may in addition serve as a motivational example to start resuscitation early in public information campaigns.
- [Homozygous and compound heterozygous RYR1 mutations : New findings on prevalence and penetrance of malignant hyperthermia.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 23.
Malignant hyperthermia (MH) is a life-threatening, acute pharmacogenetic disorder mostly due to heterozygous mutations in the ryanodin receptor 1 (RYR1) gene. Diagnosis is generally confirmed by the in vitro contracture test (IVCT). In this study the genotype-phenotype correlation was analyzed and the presumed prevalence of MH is discussed.After the diagnosis of MH susceptibility by the IVCT DNA samples of 44 patients were analyzed for mutations in the RYR1 gene using the polymerase chain reaction and sequencing. For genotype-phenotype correlation, the mutation analysis data were compared with the IVCT data.Out of the 44 patients tested 13 were identified with a heterozygous mutation, 1 patient with a homozygous mutation (c.1840C>T) and 1 patient with compound heterozygous mutations (c.1840C>T and c.6487C>T). The two patients with two mutated alleles showed a stronger response in the IVCT compared to those with only one mutated allele. Patients with one RYR1 mutation displayed significantly higher contractures in the IVCT than patients without RYR1 mutations.In the two patients described the presence of two mutated RYR1 alleles seemed to have an additive effect on the functional restriction of the (RYR1 receptor and to lead to a stronger response both in the IVCT and with regard to clinical signs. The patients with no detected RYR1 mutations possibly have a RYR1 mutation with smaller effects outside the hot spot regions tested and/or false positive IVCT results. The data from a small patient group indicate a substantially higher prevalence of MH with a correspondingly lower penetrance in the German population than previously assumed.
- [Complications in pediatric anesthesia.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 10.
As in adult anesthesia, morbidity and mortality could be significantly reduced in pediatric anesthesia in recent decades. This fact cannot conceal the fact that the incidence of anesthetic complications in children is still much more common than in adults and sometimes with a severe outcome. Newborns and infants in particular but also children with emergency interventions and severe comorbidities are at increased risk of potential complications. Typical complications in pediatric anesthesia are respiratory problems, medication errors, difficulties with the intravenous puncture and pulmonal aspiration. In the postoperative setting, nausea and vomiting, pain, and emergence delirium can be mentioned as typical complications. In addition to the systematic prevention of complications in pediatric anesthesia, it is important to quickly recognize disturbances of homeostasis and treat them promptly and appropriately. In addition to the expertise of the performing anesthesia team, the institutional structure in particular can improve quality and safety in pediatric anesthesia.
- [Use of biomarkers in sepsis : Update and perspectives.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 9.
Sepsis and related complications are a challenge for intensive care medicine. Despite many advances in antibiotic therapy sepsis remains one of the most common diseases of patients in intensive care units and is designated as the main cause of death in critically ill patients. Persisting sepsis leads to impaired immunity, resulting in immunosuppression. Unspecific predictive signs complicate an early diagnosis; however, an early initiation of adequate therapy is of crucial importance for the prognosis. Scoring systems can be applied for the initial evaluation but are controversially discussed concerning the monitoring of disease progression and therapy as well as outcome prediction. Biomarkers are considered as a complementary approach.
- [Monitoring of liver function in the critically ill.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 6.
Liver failure and hepatic dysfunction represent diagnostic and therapeutic challenges for the intensivist. Besides acute liver failure, hypoxic hepatitis, sepsis and (secondary) sclerosing cholangitis may lead to massive liver dysfunction with subsequent multiorgan dysfunction syndrome that limits survival. Among classical laboratory parameters (so-called static liver parameters) liver function tests may help with the diagnosis to allow early treatment or prevention of liver dysfunction. The aim of this article is to present the current aspects of liver function monitoring and to provide guidelines to the intensivist for diagnosing liver dysfunction in the intensive care setting.