Die Anaesthesiologie最新文献

Transoral robot-assisted surgery (TORS) enables minimally invasive procedures in the areas of the mouth, palate, pharynx, larynx and tonsils. It offers numerous advantages such as enhanced precision, improved access and reduced surgical trauma compared to traditional, more invasive techniques; however, TORS also presents new anesthesiological challenges, particularly concerning airway management, anesthesia management and perioperative care. These aspects are the focus of this review. A key issue in TORS is airway management as many patients present with risk factors for a difficult airway, while at the same time it is essential to minimize obstruction of the surgical field and access. Several options are available for securing the airway during TORS. This article outlines and discusses the advantages and disadvantages of the various techniques. Special attention is paid to a novel ultra-thin endotracheal tube known as the Tritube©, which thanks to its slim design opens up new surgical and anesthesiological possibilities. The associated technique of flow-controlled ventilation (FCV) is discussed and compared to more established ventilation methods such as volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). This article aims to provide an overview of anesthesia management in TORS, highlight potential risks and outline strategies to mitigate them.

Background: Since the introduction of three-dimensional transesophageal echocardiography (3D-TEE) in 2007, the technique has been incorporated into the guidelines of both national and international societies for intraoperative and peri-interventional TEE examinations. It is recommended for most cardiac surgical procedures and interventional transcatheter interventions but the actual use in the clinical routine has not been investigated.

Objective: Despite its growing adoption, data on the clinical application of 3D-TEE remains limited. To address this gap, the research group, in collaboration with the German Society of Anesthesiology and Intensive Care Medicine (DGAI), conducted a survey of all German departments performing cardiac surgery. The survey aimed to assess the intraoperative and peri-interventional use of 3D-TEE, structural conditions, equipment availability, imaging modalities and potential limitations encountered in daily clinical practice.

Material and methods: A representative individual for echocardiography from each of the 81 German departments offering cardiac surgery was invited via email to participate in a 25-item online survey. The survey was created using LimeSurvey software, and the results were subsequently analyzed. Subanalyses were performed for two subgroups: 1) proportion of certified anesthesiologists in the department (high vs. low certification rate) and 2) presence of a standardized image acquisition protocol (available vs. not available). Responses to the remaining questions were analyzed for these subgroups.

Results: Of the 81 German departments, 54 (67%) completed the questionnaire. More than half of the respondents reported a low TEE certification rate and 82% of departments lacked a formal 3D-TEE training program. Of the departments 4% did not have 3D-capable TEE devices, while 68% of departments had 1 device available per operating room. The 3D-TEE was frequently used in 91% of cases for transcatheter edge-to-edge repair (TEER) of the mitral and tricuspid valves, in 74% of cases for surgical valve procedures and in 57% of cases for coronary artery bypass graft (CABG) surgery. The presence of a standardized 3D image acquisition protocol was associated with more frequent TEE examinations and a greater perceived impact of 3D-TEE on daily cardiac surgical practice. A higher certification rate was linked to more frequent use of 3D modalities, increased use of 3D measurements and greater utilization of 3D-TEE for anatomical understanding and educational purposes. In Germany, intraoperative TEE for common procedures, such as heart valve surgery and bypass surgery is almost exclusively performed by cardiothoracic anesthesiologists. The most significant limitations in daily clinical practice were insufficiently trained personnel (61%) and insufficient time (57%).

Conclusion: The survey reveals that the impl

Pediatric airway management can be much more difficult due to physiological and anatomical characteristics. Special attention should be paid to signs for a difficult airway when taking an anesthesiological anamnesis. This applies especially to children with syndromale diseases. During the induction of a general anesthesia, special attention should be paid to an optimal positioning of the child`s head (avoidance of a steep reclination or flexion of the head) and a correct "utilization" of the ventilation facemask. Securing the pediatric airway with a laryngeal mask can provide decisive advantages, especially for the less experienced as it is much simpler to manage. For endotracheal intubation apneic oxygenation should be used in every case, in order to prolong the apneic tolerance and to prevent oxygen desaturation. Video laryngoscopy should now preferentially be used in pediatric anesthesia, whereby both direct and indirect laryngoscopy-techniques can be performed. A change of the laryngoscope is no longer necessary and the first-pass success of the endotracheal tube is increased. The extubation can be performed with the child in both the supine or lateral position and also awake or asleep. The various possibilities have different advantages and disadvantages and should be used according to the preference of the anesthetist caring for the individual child.

For patients with end-stage heart failure durable left ventricular assist devices (LVADs) are increasingly being used as an alternative to heart transplantation. Treatment with LVADs significantly improves both the survival rate and quality of life. The increasing prevalence of heart failure, particularly in older patients, combined with improved survival under LVAD therapy, has led to a growing population of LVAD recipients. As a result, anesthesiologists are increasingly faced with the challenge of providing specialized care for LVAD recipients. While elective procedures are mostly performed in specialized centers, emergency surgery can be required in any hospital. This article highlights the unique aspects in anesthesiological and perioperative management for LVAD patients undergoing noncardiac surgical procedures and interventions. Pathophysiological changes due to LVAD support as well as the obligatory anticoagulation, contribute to an increased risk of (spontaneous) bleeding complications in LVAD patients. Based on the only currently approved LVAD in Germany, the HeartMate 3, this article explains key LVAD operating parameters and discusses typical complications. Perioperative management must address the frequently impaired right ventricular function and ensure an appropriate hemodynamic monitoring. This article provides an overview of the perioperative care of LVAD patients to enhance their safety throughout the perioperative course.

The primary goal of intensive care medicine is to overcome a critical phase of illness using all available means and to enable patients to survive and return to an independent life without intensive care. However, this therapeutic goal cannot always be achieved. The possibility of death, the need to alleviate suffering, and respect for the end of life make it necessary to integrate palliative approaches into intensive care medicine. Supporting seriously ill and dying patients and their relatives in intensive care units requires an attitude that holistically recognizes and respects their individuality and is shared by the entire team. In addition to recognizing life and death, reliable structures, clear agreements, and palliative care skills among the respective professional groups are necessary. When implementing these approaches, it is important to remain within the framework of legal requirements and to take the wishes of those affected into account. In addition to the relevant professional expertise, the most important tool is respectful and clear communication with all those involved and affected. Help should be available at all times in cases of uncertainty regarding ethical and palliative issues, as well as in cases of psychological stress.

Along with early administration and the selection of the right drug, it is important to consider pharmacokinetic and pharmacodynamic principles, especially in life-threatening infections. Therefore, successful antibiotic therapy requires a clear understanding of the relationship between microbiology, pharmacology, and intensive care medicine. Open and transparent communication among professionals is essential for improving the quality of care. This article discusses current concepts and controversies by presenting a relevant case study of community-acquired pneumonia. It aims to help clinicians select the right drug for each patient, including the correct dose, the appropriate administration, and the right duration of treatment.