Die Anaesthesiologie最新文献

Work-related fatigue is a serious psychophysiological phenomenon characterized by exhaustion, impaired concentration, reduced alertness and diminished decision-making capacity. It often results from disrupted sleep patterns and shift work and increases the risk of critical incidents in the clinical practice. Anesthetists are particularly affected as irregular working hours and frequent night shifts disrupt their circadian rhythms. Although fatigue is reversible with appropriate measures, it remains largely unrecognized as a structural issue within the German healthcare system.Over recent decades the working conditions across European healthcare settings have steadily deteriorated, a trend that culminated during the COVID-19 pandemic. This period clearly highlighted the urgent need to prioritize the well-being of healthcare professionals. The aim of this review article is to raise awareness of fatigue and provide insights into effective management strategies. It explores both international concepts and local solutions relevant to the German system.This review and analysis are based on studies and material developed as part of the European "Fatigue Project" and the "Fight Fatigue" campaign. It examines the effects of fatigue across all career stages and identifies practical strategies for risk reduction.The results show that fatigue affects anesthetists at all stages of their careers. Structured fatigue management is therefore a vital component of sustainable healthcare provision. In particular, fatigue risk management systems and optimized shift work planning have proven effective in reducing the burden on personnel and enhancing patient safety.

The treatment of polytraumatized patients is challenging. Intensive efforts and interdisciplinary teamwork have improved survival rates of severely injured patients over the last decades. High quality guideline recommendations focusing on the prehospital setting, emergency room management and also the initial surgical phase have been published and are frequently updated. The current manuscript is part of new guidelines on an S3 level that focuses on treatment of polytraumatized patients who were transferred to the intensive care unit after initial emergency treatment. These patients have special needs, especially with respect to monitoring, pain management, ventilation strategy, nutrition etc. and most often require definitive surgical stabilization of injuries to the thorax, abdomen, pelvis and extremities. This article summarizes the current literature and gives recommendations with respect to early definitive treatment of patients with multiple trauma and particularly with a view to the best possible timing of the definitive treatment.

Volatile anesthetics represent a relevant yet largely avoidable source of greenhouse gas emissions in the healthcare system. In Germany, their use accounts for approximately 69 kt of CO₂ equivalents annually. While desflurane is used in only about 3% of inhalation anesthesia procedures, it is responsible for more than 50% of the associated emissions due to its extremely high global warming potential. Modelling studies indicate that complete substitution of desflurane with sevoflurane would reduce total emissions by approximately 53%; replacing isoflurane as well would increase the reduction to 65%. From a clinical perspective, desflurane offers no proven advantage over sevoflurane with respect to patient safety or postoperative outcomes. Isoflurane likewise shows no clinical superiority. This creates substantial scope for substitution without compromising quality of care. Under minimum alveolar concentration (MAC)-adjusted conditions, desflurane causes an approximately 34-fold higher global warming per anesthesia hour than sevoflurane. The contrast is even greater when compared to total intravenous anesthesia (TIVA). Of particular relevance is the short-term climate impact. Due to its high radiative efficiency, desflurane exerts most of its warming effect within a few decades, precisely the critical period up to 2050. In addition, volatile anesthetics contribute to environmental contamination with persistent perfluoroalkyl and polyfluoroalkyl substances (PFAS), posing potential long-term risks to ecosystems and human health. Eliminating desflurane requires no new infrastructure, is economically rational and can be implemented immediately. It hence represents a rare opportunity in the healthcare system to achieve rapid and substantial emission reductions through a simple clinical decision, while maintaining patient safety and quality of care.

Background: A comprehensive transesophageal echocardiography (TEE) examination is nowadays common practice in cardiac surgical procedures. The introduction of 3D technology enables a simultaneous multiplane display of 2D views (X-plane) which can shorten the duration of the TEE examination; however, X‑plane imaging results in a decrease in temporal resolution which can affect the accuracy of routine anatomical linear measurements. The 3D-TEE imaging enables multiplanar reconstruction of 3D datasets and to freely position perpendicular 2D planes to measure anatomical structures more accurately, which has been shown to strongly correlate to computed tomography and magnetic resonance imaging.

Objective: Does the integration of multiplane imaging shorten the time of a comprehensive TEE examination without affecting the accuracy of routine 2D anatomical linear measures?

Material and methods: In a prospective randomized comparative study, patients scheduled for elective cardiac surgery underwent a comprehensive intraoperative TEE examination (Philips CX 50 with X‑72T probe). They were divided into two groups. In the routine protocol (RP) group, the TEE examination was conducted according to the standardized departmental image acquisition protocol, while in the study protocol (SP) group, multiplane views were integrated into the RP to replace the corresponding 2D views. The examinations were conducted by two experienced echocardiographers. At the end of the assigned examination protocol the timer was stopped and the missing views were obtained (2D for the X‑plane and vice versa) as well 3D datasets of the mitral valve, aortic valve and left ventricle. Measurements of mitral and aortic annuli as well as left ventricular length from 2D and X-plane views were subsequently performed offline. Measurements obtained from a multiplanar reconstruction of a full volume (FV) 3D dataset from the same patient were used as the gold standard to compare measurements in RP and SP.

Results: The examination time was significantly shorter in the SP group (SP: 481 ± 60 s; RP 595 ± 60 s; p < 0,001). There was no significant difference for any of the measurements using the SP and RP. The mean percentage error, although not statistically significantly different, was numerically smaller for the X‑plane than for 2D method compared to 3D except for the mitral valve annulus. Overall, X‑plane tended to show lower variability compared to 2D.

Conclusion: Integrating multiplane views into a standardized comprehensive TEE image acquisition protocol reduces the examination time. The accuracy of standardized linear measurements in X‑plane mode is comparable to that of conventional 2D imaging.

Background: Severely injured children account for only a small proportion of emergency medical service (EMS) missions but pose major challenges to the emergency teams due to age-related anatomy and physiology, complex injury patterns and high emotional stress. This narrative review summarizes the current evidence on the epidemiology and prehospital management of pediatric trauma patients in the German EMS system and places these findings in an international context.

Material and methods: A PubMed search was carried out using the terms "children", "trauma" and "prehospital". Studies reporting the prehospital management of injured children and adolescents were included. Out of 421 records 20 studies were selected and complemented by backward citation searches, with a focus on data from Germany and comparable high-income countries.

Results: Pediatric emergencies account for approximately 5% of ground EMS (GEMS) and 6-13% of helicopter EMS (HEMS) missions; severely injured children (e.g. NACA IV-VII) constitute only a small fraction, making pediatric polytrauma a classical low-frequency, high-impact scenario. The proportion of traumatic emergencies increases with age and peaks during adolescence; boys are overrepresented in all cohorts. Falls and traffic incidents dominate, predominantly resulting in blunt trauma with injuries mainly to the head and extremities. Polytrauma is reported in only around 5% of injured children and primarily affects older children and adolescents. Oxygen administration, intravenous access, immobilization and analgesia are frequent measures, whereas intubation, intraosseous access, chest drainage and other invasive procedures are rare. Several studies indicate an association between HEMS or direct admission to a (pediatric) major trauma center and improved survival.

Conclusion: Pediatric trauma patients represent a small but high-risk group in whom invasive procedures must be performed under time pressure and emotional stress. The management of complex cases by specialized HEMS teams and clearly designated (pediatric) major trauma centers, the strengthening of paramedic-based care, simulation-based training, standardized prehospital and in-hospital outcome-oriented data collection and the further expansion of regionally coordinated trauma networks are key steps towards improving prehospital care for injured children.

The publication in 2025 of the first S3 level guidelines on renal replacement therapy (RRT) in intensive care medicine provides the comprehensive, evidence-based recommendations for critically ill patients with acute kidney injury (AKI). They define absolute indications that require the immediate initiation of RRT. Acute kidney injury (AKI) requiring RRT is common in the ICU and is associated with increased mortality. A narrative review of the new guidelines was performed by extracting and appraising recommendations on initiation, modality selection, anticoagulation, dosing, anti-infective therapy, weaning and post-ICU follow-up. Immediate RRT is mandated for absolute indications, such as life-threatening and refractory hypervolemia, electrolyte, acid-base or uremic disturbances. In the absence of these, a proactive early start is advised if the overall clinical picture (comorbidities, disease trajectory and the patients current condition) suggests a high likelihood of RRT becoming necessary. In other cases, a conservative management is possible. Continuous and intermittent techniques are considered therapeutically equivalent, whereby continuous or prolonged procedures are given priority in cases of hemodynamic instability. In cases of severe hyperkalemia a diffusive procedure with high dialysis flow is recommended. Regional citrate anticoagulation is preferred in patients with a risk of bleeding. For continuous RRT an effluent dose of 20-25 ml/kg body weight h^-1 is advised, whereas intermittent dosing is individualized without a fixed target. In anti-infective treatment the initial dose should not be reduced and is given as short infusions. The role of dose-adjustment tools and therapeutic drug monitoring are emphasized. Before a weaning attempt, volume overload, hyperkalemia and metabolic acidosis should be corrected. The return to spontaneous diuresis is the most reliable predictor for successful weaning. Stable renal function for at least 7 days defines the primary success of weaning. All survivors of AKI should receive structured outpatient follow-up after hospital discharge. The new guidelines provide for the first time integrated recommendations for action for RRT in the critically ill, aiming to improve the quality of treatment and standardization in German-speaking intensive care units.

Background: A regression model to estimate the duration from the onset of resuscitation efforts to the return of spontaneous circulation (ROSC) could help improving both resuscitation care and the quality control of registries. This study aims to evaluate the prediction accuracy and to identify challenges for future model development.

Method: Regression models based on M5P, random forest (RF) algorithms and a linear regression (LR) modified using M5P were retrospectively developed using a Belgian cohort of 84 individuals in whom ROSC was achieved. Model performance was assessed using quality metrics, such as the correlation coefficient (CC), coefficient of determination (R²), and root mean square error (RMSE) in a cross-validation approach.

Results: In the cohort 61.9% were male with a mean age of 65.7 years. A shockable rhythm was present in 27.7% of cases and the bystander cardiopulmonary resuscitation (CPR) rate was 48.2%. The no-flow time averaged 5.13 min. The mean time from CPR onset to first defibrillation was 7.81 min and to first medication administration 11.31 min. The ROSC occurred after an average of 16.8 min, the LR showed the highest correlation (0.73, 95% confidence interval, CI 0.72-0.74) and R² (0.53 [0.52-0.55]) along with the lowest RMSE (6.76 min [6.63-6.90]). The M5P yielded similar not significantly different values (CC 0.72 [0.70-0.73], R² 0.52 [0.50-0.53], RMSE 6.84 min [6.69-6.99]). In contrast, RF performed significantly worse (CC 0.62 [0.61-0.63], R² 0.38 [0.37-0.40], RMSE 7.89 min [7.82-7.96], all p < 0.01). Only LR showed no significant difference between predicted and actual values in terms of mean (p = 0.75) and variance (p = 0.15). The proportion of potentially prematurely terminated resuscitation attempts, defined as cases with actual ROSC occurring later than predicted ROSC plus RMSE, ranged from 13% (M5P) to 18% (LR).

Conclusion: The duration from the start of CPR to ROSC appears to be a process that is suitable for modelling with machine learning algorithms. At this early stage of development, the individual regression models did not demonstrate sufficient validity possibly due to low sample size and simplified data structure; however, the findings indicated potential for an application as a quality assurance tool to compare actual vs. predicted time to ROSC. Therefore, to increase the robustness the results require further evaluation in a larger cohort with additional variables and improved data quality based on the Utstein criteria.