Die Anaesthesiologie最新文献

Perioperative bleeding is and remains a major complication during and after surgical interventions, resulting in increased morbidity and mortality. The main causes of a non-primary vascular-related bleeding are congenital or multifactorial pre-existing hemostatic disorders that have not yet been diagnosed, the operating procedure itself and acquired hemostatic abnormalities as a secondary phenomenon, e.g., after excessive volume depletion in hypothermia, trauma or extracorporeal circulation, concomitant hypothermia and loss or consumption of coagulation factors and thrombocytes. Beginning with the preoperative preparation, including an extensive medical history, the detection of potential risk factors for increased bleeding including the precise description of current medication is required and prophylactic strategies and procedures should be initiated. In cases of excessive bleeding it is essential to implement adequate diagnostic and therapeutic algorithms, which are suitable for the partly complex and variable alterations of the hemostasis (e.g., in interventions after trauma or with extracorporeal circulation). A multimodal management is necessary to improve the patient's outcome, to limit the administration of blood products to that which is absolutely necessary and to minimize the risks associated with transfusion.

Every day blood losses are visually estimated by medical personnel (physicians, midwives, paramedics) because an exact quantitative measurement is impossible or impractical. Anesthesiologists are confronted with blood loss in the operating room, in the delivery room, in the emergency room and at the scene of an emergency; however, the literature shows that in all the named areas enormous errors occur in the visual estimation. Errors of 50% and more are not uncommon, which means that, e.g., an estimated blood loss of 2000ml could actually be 3000ml or only 1000ml. General, in all the abovenamed areas blood losses are more likely to be underestimated than overestimated. The ability to make an estimation is not improved by professional experience. The amount of blood loss indicates and "justifies" invasive measures and the administration of blood and cost-intensive blood products. This overview is dedicated to the problems in the estimation of blood loss, demonstrates the sequelae of an incorrectly estimated blood loss, provides tips on how the ability to make an estimation can be improved and describes the considerable potential of further education as well as which digital support options are now available.

Since the last surveys on the utilization of muscle relaxants in general anesthesia in 2000 and 2005, it can be assumed that the introduction of sugammadex for the rapid and safe reversal of neuromuscular blocks as well as the establishment of new surgical techniques, have had an impact on the use of muscle relaxants in general anesthesia. A web-based questionnaire was used to survey anesthesia departments and outpatient surgery centers regarding the use of neuromuscular blocking agents. The aim was a comparison with previous surveys and the statistical analysis was descriptive. The response rate of the 1027 anesthesia departments contacted was 16.5%. The availability of neuromuscular monitoring in hospitals continues to improve. The most frequently used drug for rapid sequence induction is now rocuronium rather than succinylcholine. Sugammadex is now available as a drug in 86% of the responding anesthesia departments. The concept of complete relaxation for laparoscopic surgery called deep block is used by 60% of those surveyed. The results are analyzed and discussed in the context of the first European guidelines published in 2023 by the European Society of Anaesthesiology and Intensive Care (ESAIC). They show that with respect to the use of succinylcholine and the support by new surgical techniques have changed the management of neuromuscular block since the last surveys. The use of neuromuscular monitoring to control the management of muscle relaxation is still not standard in all hospitals, so that an additional patient risk cannot be ruled out.

Background: This prospective observational study aimed to explore the frequency and risk factors of rebound pain (RP) in patients treated with multimodal analgesia and intravenous dexamethasone following a peripheral nerve block (PNB).

Material and methods: All patients who received preoperative PNB were given a standard multimodal analgesia regimen and intravenous dexamethasone. Motor and sensory block durations, RP severity and frequency were measured for the first 24 h post-PNB using a semistructured questionnaire. The RP was identified as acute postoperative pain within the first 12-24 h after sensory blockade resolution. The severity of RP was determined through the rebound pain score. Contributing risk factors to the development of RP were investigated.

Results: After the PNB had worn off RP developed in 27.7%. The following were identified as independent risk factors for RP: patient age, with an adjusted odds ratio (AOR) of 2.3 and a 95% confidence interval (CI) of 1.4-3.9, the use of bupivacaine in combination with lidocaine or prilocaine (AOR: 2.1, 95% CI 1.2-3.8), preoperative pain (AOR: 2.8, 95% CI 1.3-5.6), bone surgery (AOR: 1.8, 95% CI 1.0-3.0) and the duration of the surgery (AOR: 2.8, 95% CI 1.5-5.1).

Conclusion: An exact identification of risk factors for RP can aid in creating preventative strategies that target changeable elements. A comprehensive understanding of this occurrence by PNB practitioners can lead to more effective use of PNB, decreased RP instances and improved outcome optimization.

Anaesthesiology and intensive care medicine are innovative specialist areas that mainly use the advantages of digital documentation. However, to exploit the full potential of the digital age, more than conversion of paper-based documentation into digital formats is required. The German healthcare system needs to catch up; more than money is required to drive digitalisation forward. The willingness of all those involved to adapt to new circumstances is essential-a process known as 'digital transformation'.The drivers of digital transformation in medicine are the need for personalised therapies, technological advances, and shared decision-making between physicians and patients. However, humans should take centre stage in medicine; technology is only a means to an end.As data-driven research is becoming increasingly important, the FAIR principles must apply to routine data in the same way as it is propagated for research: Data must be findable, accessible, interoperable and reusable. Utilising high-quality databases, decision support, and warning systems can be developed for early recognition and prevention of complications.Teleintensive care is a concrete expression of digital transformation. The COVID-19 pandemic paved the way for it to become standard care.Digital technologies in education and training are becoming increasingly popular. Virtual and augmented reality applications enable realistic training scenarios for trainee physicians and experienced teams.In the future, expanding the infrastructure and facilitating data exchange between all healthcare areas is essential. Applications must be reliable and secure, as cybercrime poses a severe threat to our hospitals, making vigilant IT departments and education in IT security crucial. In summary, digitalisation can make patient care safer and better if implemented correctly and involving all stakeholders.

Background: The medical treatment by emergency paramedics without the presence of an emergency physician in Germany is based primarily on 1) delegation by the Medical Director of Emergency Medical Services (AELRD) or 2) the independent practice of medicine according to § 2a of the German Federal Emergency Paramedic Act (NotSanG). Both possibilities differ with respect to the responsibility for the diagnosis and treatment decision. This article provides for the first time a nationwide overview of who bears which responsibilities for treatment specifications for emergency paramedics.

Material and methods: The treatment algorithms for five clinical pictures were evaluated for all German federal states with respect to their geographical validity, the declaration and objective character as the delegation by the AELRD or the practice of medicine (§ 2a NotSanG) and the extension to narcotics. The data collection took place between December 2020 and June 2022.

Results: In this study 112 algorithms with 403 individual measures were analyzed. For 11 German states unified treatment specifications were found and in 5 federal states treatment specifications differing from region to region were identified. The AELRD delegation or § 2a NotSanG status was explicitly declared in only 40% of the individual measures. This declaration was consistent with the objective character of the measure in 93%. An independent narcotics administration by paramedics is established in six states.

Conclusion: In the majority of measures intended for paramedics it is not obvious whether they are to be applied according to AELRD delegation or § 2a NotSanG. Such a declaration by the preparers could provide more clarity with respect to the responsibilities. Both an AELRD delegation and the administration of narcotics by paramedics without the presence of a physician are not established in all German states. Due to the continuously developing legal situation, the investigated endpoints may have changed in the meantime in some regions.

Postoperative nausea and vomiting (PONV) is defined as the joint or individual occurrence of nausea, retching and vomiting within 24-48h after an operation. The peripheral and central nervous systems are involved in the development of PONV. The pathogenesis of PONV is multifactorial. Patient-related, anaesthesia-related and surgery-related risk factors can be present. Some of the risk factors for PONV were combined to form PONV risk scores (e.g., the simplified risk score for predicting postoperative nausea and vomiting from Apfel et al.), with the help of which the risk of PONV can be estimated with a sensitivity and specificity of 65-70%. For certain collectives specialised PONV risk scores should be prioritised. The antiemetic strategy is divided into three areas: modification of the anaesthetic procedure, pharmacological and nonpharmacological interventions. These can be applied individually or combined in the sense of a multimodal PONV prophylaxis.