Die Anaesthesiologie最新文献

Perioperative and periprocedural bleeding complications substantially increase the morbidity and mortality. The main causes are intervention-related or trauma-related factors, patient-related factors, such as congenital or acquired hemostatic disorders as well as pre-existing medicinal anticoagulation as a result of the underlying disease. Despite the variety of currently available test procedures, the constellation of a clinically relevant bleeding situation without tangible pathological laboratory findings or causes often occurs. This constellation, called bleeding disorder of unknown cause (BDUC), requires a structured diagnostic and therapeutic approach to improve the outcome of the patient, to avoid a therapeutic polypragmasia and to limit the administration of hemostatics to that which is absolutely necessary. The close monitoring of these patients, whose quality of life is often restricted, is meaningful and necessary.

Historically, plasma was first used as volume replacement and later for coagulation substitution, although with limited effectiveness. As almost coagulation neutral volume replacement agents, plasma products are useful in treating patients suffering from traumatic hemorrhagic shock and seem to be superior to crystalloid infusion solutions for improving the outcome. Various plasma products are currently available on the market, each offering different advantages and disadvantages, which necessitates careful selection. The transfusion of plasma products should have the same AB0 group but in time critical emergencies AB0-compatible plasma can also be used. The previously feared risk of infection has been significantly reduced thanks to improved donor selection, testing and manufacturing processes, so that today other side effects are more prominent. Common side effects, such as iatrogenic hypocalcemia and transfusion-associated circulatory overload, must be considered. Careful evaluation of the correct indications for plasma transfusion can greatly reduce the occurrence of adverse events. For anesthesiologists the main indications for transfusion of plasma products are the treatment of hemorrhagic shock and, in exceptional cases, the substitution of rare individual factor deficiencies; however, in practice, there are often incorrect indications, which is why the administration should be critically reviewed before each plasma transfusion. The current literature no longer recommends the prophylactic use of plasma prior to procedures (e.g., tracheostomy, central venous catheter placement) in patients with abnormal coagulation tests but no evidence of bleeding. Patients with (chronic) liver dysfunction and abnormal coagulation parameters but without clinical correlates, should also not receive transfusions. Further research is still required to determine whether plasma plays a role in sepsis and in patients suffering from severe burns.

The updated S1 guideline from the German Society of Anesthesiology and Intensive Care Medicine provides recommendations on hygiene practices for central and peripheral regional anesthesia procedures, aiming to minimize the infection risk for patients. Central to the guideline is the consistent implementation of standardized hygiene measures, with particular emphasis on thorough hand hygiene by the practitioners before and after each procedure. Patient skin preparation should be performed directly with remanent, alcohol-based disinfectants, provided there is no visible contamination. Hair removal is recommended only when necessary, preferably using clippers. For all neuraxial procedures, the use of a face mask, head cover, and sterile gloves is mandatory. In the case of single-shot peripheral nerve blocks, the use of non-sterile disposable gloves may be acceptable depending on the circumstances. Only sterile single-use materials and freshly withdrawn medications from single-dose containers should be used to prevent crosscontamination. In ultrasound-guided procedures, the use of a sterile probe cover and thorough disinfection of the ultrasound transducer before and after use are obligatory. For indwelling regional anesthesia catheters, the insertion site must be inspected daily; dressing changes should be performed only when infection is suspected or when there is an evident clinical indication. Catheter tunneling and the use of chlorhexidine-containing dressings may contribute to reducing bacterial contamination. If signs of infection occur, targeted diagnostics and infection-specific treatment should be initiated, according to the severity of the clinical presentation. Additionally, the guideline recommends the introduction of hygiene bundles, standardized procedural kits, and regular staff training. These measures should be subject to continuous evaluation and optimization via structured monitoring and benchmarking. All recommendations must be adapted to local conditions and institution-specific hygiene protocols.

According to data from the World Health Organization (WHO), approximately 300 million surgical procedures are performed worldwide each year. The majority of these procedures are conducted with the patient under general anesthesia, with endotracheal intubation used to secure the airway in more than half of the cases. Complications during airway management can lead to serious adverse events and significantly contribute to perioperative morbidity and sometimes even mortality.Over the past 25 years, the increasing use of video laryngoscopes in clinical practice has led to substantial advancements in the management of difficult airways. This has resulted in a marked reduction in potentially severe complications, establishing video laryngoscopes as an indispensable tool in modern anesthesia practice; however, a critical question remains: why has video laryngoscopy become the standard approach for anticipated and unanticipated difficult airways but is not (yet) routinely employed as the primary method for all intubations?Both meta-analyses and randomized controlled trials have confirmed the superiority of video laryngoscopy in airway management across various patient populations and clinical scenarios. Video laryngoscopy improves the first attempt success rate of intubation, while simultaneously reducing the total number of intubation attempts, the incidence of airway injuries and the rate of failed intubations. Consequently, in alignment with the current German S1 guidelines on airway management, the adoption of video laryngoscopy as a potential standard technique for all intubations is recommended.The benefits of video laryngoscopy clearly outweigh the arguments against its universal application. It should therefore be adopted as the primary intubation technique in order to enhance patient safety and improve the overall quality of airway management.

Background: The management of sepsis patients remains an ongoing challenge in intensive care medicine and leads to unacceptably high morbidity and mortality rates, even in medically highly developed countries.

Objective: What is the state of the quality of early sepsis treatment on German intensive care units (ICUs)?

Material and methods: To assess the quality of early sepsis treatment, we conducted a nationwide internet-based survey among members of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI).

Results: A total of 1935 intensive care physicians across Germany were surveyed of whom 459 experienced specialist physicans responded, including 38% chief physicians and 61% senior physicians. Overall, 66% of participants reported the use of screening tools for early sepsis detection, with the quick-sepsis organ failure assessment (qSOFA) being the most frequently used (71%). In 32.7% of the surveyed ICUs a microbiologist was available around the clock. Interdisciplinary rounds involving a microbiologist or a clinical pharmacologist took place in 55.5% and 52.5% of ICUs, respectively. Molecular diagnostic procedures (e.g., SeptiFast®) for rapid pathogen identification were available in only 10.9% of the surveyed ICUs.

Discussion: In summary, the use of the qSOFA score remains widespread despite deviating recommendations in current international guidelines. Additionally, interdisciplinary rounds involving microbiology or pharmacology were conducted in only half of the participating ICUs. Molecular biological diagnostic procedures are still not part of the diagnostic standard in most hospitals.

Background: Cases of poisoning account for 3-7% of all emergency medical services (EMS) calls. At present it is not known which toxins are responsible for severe and fatal poisoning in Germany.

Methods: In this study, all cases of poisoning with a severe or fatal course reported to the Poisoning Information Center (GIZ) North by the emergency services over a 5-year period were analyzed. The severity of poisoning was classified using the poisoning severity score (PSS) [4] and the causative noxious agents were assigned according to the anatomical therapeutic chemical (ATC) classification system [6].

Results: In 259 cases out of 8528 consultations by the EMS the poisoning was severe and in 14 cases it was fatal. Most commonly involved were patients between 20 and 49 years. In 221 (81%) of these cases the poisoning was with suicidal intent and most often at home. In 199 cases the cause was pharmaceuticals, mostly taken by women (60.8%). Most substances were pharmaceuticals with effects on the central nervous system, the second most frequent but only in 16 cases were drugs with effects on the cardiovascular system. Chemical products accounted for 29 (10.6%) and drugs for 14 (5.1%) of the cases. The outcome was fatal in 14 (5.1%) patients. Most of these patients were already dead when found and resuscitation efforts were unsuccessful. Of the patients three were transported to hospital but were dead on arrival. In fatal intoxications suitable specific antidotes were principally available only in three cases but resuscitation efforts were either no longer indicated or were unsuccessful.

Conclusion: This study shows that most severe and fatal poisonings occur at home with suicidal intent using pharmaceuticals. Due to the possible number of different substances and the possible combinations, it is not possible for EMS personnel to assess all effects and substance interactions. If contacted early, due to their access to large data banks poisoning information centers are able to provide important recommendations with respect to symptomatic and further treatment as well as to suitable target hospitals.

Hypertensive diseases of pregnancy (HES) affect approximately 6-8% of all pregnancies and contribute to 20-25% of perinatal mortality globally. Among these, preeclampsia represents the most severe manifestation, contributing to over 70,000 maternal and 500,000 perinatal deaths anually worldwide [1]. In July 2024, the updated S2k guidelines on hypertensive diseases during pregnancy (HES) were published, presenting updated recommendations for improved diagnosis and therapeutic strategies. Notable advancements in the revised guidelines include an emphasis on the early identification of patients at risk, implementation of individualized monitoring protocols, establishment of optimized target blood pressure thresholds, and the critical importance of long-term cardiovascular follow-up for the affected mother-ideally extending throughout the patient`s lifespan [2]. As in the previous version, the current guidelines retain a dedicated section addressing anesthesiological considerations in the peripartum period. Furthermore, they expand on the anaesthetic implications relevant to both preclinical and clinical care settings for pregnant individuals with HES. This article provides a concise synthesis of the most clinically pertinent innovations introduced in the 2024 guideline update.