Die Anaesthesiologie最新文献

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.

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.