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Wide awake local anesthesia no tourniquet (WALANT) refers to an anesthesia technique with low bleeding and complication rates, which enables interventions on the hand in an awake patient without the use of a tourniquet. Bleeding control is achieved through addition of vasoconstrictors to the infiltration solution. Since the motor function of the extremity is not affected, it offers the additional possibility of intraoperative active function testing. The WALANT procedure constitutes an established, effective, easily learnt and resource-sparing technique. The spectrum of surgical possibilities with WALANT is wide and covers nearly all elective and many emergency procedures. Due to multiple advantages in contrast to other regional and general anesthesia procedures, WALANT features an increasing spectrum of surgical applications and practitioners. It is therefore of interest for hand surgeons working both in hospitals and private practices.„Wide awake local anesthesia no tourniquet“ (WALANT) bezeichnet ein blutungs- und komplikationsarmes Lokalanästhesieverfahren, das Handeingriffe am wachen Patienten ohne den Einsatz einer Blutsperre ermöglicht. Dies wird durch den Zusatz vasokonstriktiver Substanzen in der Infiltrationslösung möglich. Da die Motorik der Extremität nicht beeinflusst wird, bietet es zusätzlich die Möglichkeit der intraoperativen aktiven Funktionsprüfung. Die WALANT-Anästhesie ist ein etabliertes, effektives, leicht erlernbares und Ressourcen schonendes Verfahren. Das Spektrum der chirurgischen Möglichkeiten mit WALANT ist breit und deckt nahezu alle elektiven und viele notfallbedingten Eingriffe ab. Aufgrund mannigfaltiger Vorteile gegenüber allgemeinen Anästhesieverfahren findet WALANT in der Chirurgie immer neue Indikationen und Anwender. Es ist daher für die handchirurgische Versorgung im klinischen wie im niedergelassenen Bereich gleichermaßen interessant.

In the attentive waking state, pleasant odours often prolong inhalation while unpleasant odours often shorten the exhalation. It should be checked whether this induced breathing pattern is maintained even during sleep.23 healthy normosmic adults were examined by polysomnography for one night and randomized pulsed either with HReaction indices with reductions of DEX were larger than spontaneous RI and RI for PEA and HWhen stimulated with an unpleasant smell in sleep, the respiratory reaction pattern from the awake state is preserved. RI with shortened DEX can be considered as an imperfect arousal.Im aufmerksamen Wachzustand verlängern angenehme Gerüche häufig die Einatmung, während unangenehme Gerüche häufig die Ausatmung verkürzen. Es soll überprüft werden, ob dieses induzierte Atemmuster auch im Schlaf erhalten bleibt.23 gesunde normosmische Erwachsene wurden für 1 Nacht polysomnografisch untersucht und dabei entweder mit HReaktionsindizes mit Verkürzungen von DEX waren bei einer HBei Reizung mit einem unangenehmen Geruch im Schlaf bleibt das respiratorische Reaktionsmuster aus dem Wachzustand erhalten. RI mit verkürzten DEX können als unvollkommene Arousals angesehen werden.

Despite the theoretical and epistemological complexities involved in dealing with the phenomenon of consciousness, the author describes defines a pragmatic and experimental methodology, based on a two-dimensional neurocognitive approach. Indeed, in order to avoid the hard problem of consciousness, it would be better to focus on the real problem, i.e. on mechanisms that can be empirically observed, leaving out all of the epistemic and phenomenological features of conscious states. The idea of a hierarchical relationship between the level (wakefulness) and the content (awareness) of consciousness could give rise to an interpretation which justifies both the unity and, at the same time, the phenomenal variety of consciousness. However, studies on sleep, REM phase and nightmares might challenge at least the strong version of this hypothetical relationship between different features of consciousness. Furthermore, it is important to consider whether a two-dimensional perspective, rather than a three-dimensional one, would be sufficient to exhaustively define all the objective features of consciousness.

There is a growing number of children surviving birth complications with severe, multiple disabilities. Unfortunately, this is not paralleled by equal growth in knowledge about adequate therapeutic approaches. Some publications showed that Hippotherapy could, under certain circumstances, be a very useful complimentary therapy for a range of disabilities. But it remains unclear if riding could even help a quadriplegic individual with multiple brain damage and tracheal ventilation.In this case study we examined the effect of horse riding on the mobility of joints and heart rate in a little girl with multiple disabilities.We found a statistically significant increase in joint mobility and a significant decrease in the heart-rate (down to a normal resting frequency). We also had a rather unexpected effect of the hippotherapy. Namely, while on horseback, the girl demonstrated a sufficient spontaneous breathing. No additional oxygen was needed.Horse-back riding helped our patient to reduce her symptoms. Therefore, it showed clear positive effects even for a girl with severe and multiple disabilities.Die Zahl der Menschen, die schwerstbehindert Unfälle oder Geburtskomplikationen überleben, steigt aufgrund verbesserter medizinischer Möglichkeiten stetig, nicht jedoch das wissenschaftlich gesicherte Wissen um geeignete Therapiemaßnahmen. Verschiedene Veröffentlichungen beschreiben die Reittherapie bereits als effiziente zusätzliche Therapiemethode, ob sie jedoch bei schwerster Behinderung mit Beatmungspflicht eingesetzt werden kann, ist bis jetzt noch ungeklärt.In dieser Einzelfallstudie wurde ein schwerstbehindertes Kleinkind mit dem Syndrom reaktionsloser Wachheit exemplarisch untersucht. Wir untersuchten den Effekt des Reitens auf Muskelspannung, Gelenkbeweglichkeit und Herzfrequenz.Die erwarteten Effekte des Reitens auf Muskeltonus, Gelenkbeweglichkeit und Herzfrequenz zeigten sich deutlich. Es ergaben sich signifikante Verbesserungen im Zustand des Kindes im Hinblick auf alle untersuchten Aspekte. Zusätzlich ergab sich ein eher unvermuteter Effekt auf die Notwendigkeit der Sauerstoffgabe und die Eigenatmung des Kindes. Während des Reitens atmete das Kind selbständig, die zusätzliche Gabe von Sauerstoff war nicht notwendig.Die Reittherapie zeigte auch bei unserer schwerst und mehrfach geschädigten Patientin positive Effekte und erwies sich hier als sinnvoller zusätzlicher Therapieansatz.

An 86-year-old woman was scheduled for surgical treatment of a periprosthetic femoral fracture after a fall. Because of a known difficult airway due to multiple surgeries and radiation for cancer in the orofacial area, awake fiberoptic intubation was planned. During the fiberoptic maneuver the patient experienced a massive bout of coughing which resulted in large soft tissue emphysema and double-sided pneumothorax. This case reports a rare complication of fiberoptic intubation and airway management.

Light, through its non-imaging forming effects, plays a dominant role on a myriad of physiological functions, including the human sleep–wake cycle. The non-image forming effects of light heavily rely on specific properties such as intensity, duration, timing, pattern, and wavelengths. Here, we address how specific properties of light influence sleep and wakefulness in humans through acute effects, e.g., on alertness, and/or effects on the circadian timing system. Of critical relevance, we discuss how different characteristics of light exposure across the 24-h day can lead to changes in sleep–wake timing, sleep propensity, sleep architecture, and sleep and wake electroencephalogram (EEG) power spectra. Ultimately, knowledge on how light affects sleep and wakefulness can improve light settings at home and at the workplace to improve health and well-being and optimize treatments of chronobiological disorders.

Study Objectives: Environmental noise exposure disturbs sleep and impairs recuperation, and may contribute to the increased risk for (cardiovascular) disease. Noise policy and regulation are usually based on average responses despite potentially large inter-individual differences in the effects of traffic noise on sleep. In this analysis, we investigated what percentage of the total variance in noise-induced awakening reactions can be explained by stable interindividual differences. Methods: We investigated 69 healthy subjects polysomnographically (mean ± standard deviation 40 ± 13 years, range 18–68 years, 32 male) in this randomized, balanced, double-blind, repeated measures laboratory study. This study included one adaptation night, 9 nights with exposure to 40, 80, or 120 road, rail, and/or air traffic noise events (including one noise-free control night), and one recovery night. Results: Mixed-effects models of variance controlling for reaction probability in noise-free control nights, age, sex, number of noise events, and study night showed that 40.5% of the total variance in awakening probability and 52.0% of the total variance in EEG arousal probability were explained by inter-individual differences. If the data set was restricted to nights (4 exposure nights with 80 noise events per night), 46.7% of the total variance in awakening probability and 57.9% of the total variance in EEG arousal probability were explained by inter-individual differences. The results thus demonstrate that, even in this relatively homogeneous, healthy, adult study population, a considerable amount of the variance observed in noise-induced sleep disturbance can be explained by interindividual differences that cannot be explained by age, gender, or specific study design aspects. Conclusions: It will be important to identify those at higher risk for noise induced sleep disturbance. Furthermore, the custom to base noise policy and legislation on average responses should be re-assessed based on these findings.

The affective valence of an olfactory stimulus will be encoded in its respiratory response. Unpleasant odors shorten the inhalation of the first stimulated breaths in wakefulness and sleep. The aim of the present study was to assess the effekt of intravenous anesthetic propofol on the chemosensory evoked changes of breathing pattern.13 ASA 1/2 patients got intranasal chemosensory stimuli (H2S and CO2) by flow-olfactometer during "deep" (EEG-based bispectral analysis, BIS:≤60) and "moderate" (BIS60) propofol-induced sedation with preserved spontaneous breathing. The duration of the in- and exhalation was analyzed for 5 breaths before and for 2 breaths after the onset of stimulation.During deep sedation respiratory reactions were observed only by CO2 irritation. During moderate sedation respiratory responses were evoked by H2S stimuli, too. In moderate sedation extensions of the inhalations of the first breath after both the unpleasant pure olfactory H2S stimuli and the trigeminal stimuli were more frequent than reductions.Olfactory stimuli change the breathing only during moderate sedation, trigeminal stimuli during deep and moderate propofol-induced sedation. In opposite to both wakefulness and sleep the duration of inhalation is often extended by H2S-stimuli during moderate sedation.

This article gives an overview of factors underlying age-related changes in sleep wake behavior in healthy older humans. The self-regulation of the sleep-wake cycle [sleep-wake homeostasis] and the circadian clock, represent primary factors responsible for changes in sleep with age. As a matter of fact older healthy adults have a more superficial and less consolidated sleep and go to bed earlier compared to younger ages. Furthermore, sleep in healthy older people is more vulnerable to disturbances such as circadian desynchronisation and the lack of zeitgebers [insufficient light during the day].Dieser Artikel gibt einen Überblick über mögliche Faktoren für altersbedingte Veränderungen, welche den Schlaf bei gesunden älteren Menschen beeinflussen. Ein wichtiger Beitrag wird hierbei durch die Selbstregulation des Schlaf-Wach Zyklus sowie die innere Uhr geleistet. Eine Quintessenz zeigt sich darin, dass ältere gesunde Erwachsene einen oberflächlicheren Schlaf und meistens frühere Bett- und Aufstehzeiten als noch in jüngeren Jahren haben, was auf altersbedingte Veränderungen in der Schlaf-Wach Homöostase und der inneren Uhr zurückzuführen ist. Zudem reagiert der Schlaf bei gesunden älteren Menschen empfindlicher auf Störungen, wie der circadianen Desynchronisation und einen Mangel an Zeitgebern [zu wenig Licht am Tage].

Circadian rhythm sleep disorders are prevalent among psychiatric patients. This is most probable due to a close relationship between functional disturbances of the internal clock, sleep regulation and mental health. Mechanisms on molecular level of the circadian clock and neurotransmitter signalling are involved in the development of both disorders. Moreover, circadian disorders and psychiatric diseases favour each other by accessory symptoms such as stress or social isolation. Actimetry to objectively quantify the rest-activity cycle and salivary melatonin profiles as marker for the circadian phase help to diagnose circadian rhythm sleep disorders in psychiatric patients. Chronotherapeutics such as bright light therapy, dark therapy, melatonin administration, and wake therapy are used to synchronise and consolidate circadian rhythms and help in the treatment of depression and other psychiatric disorders, but are still neglected in medicine. More molecular to behavioural research is needed for the understanding of the development of circadian disorders and their relationship to psychiatric illnesses. This will help to boost the awareness and treatment of circadian rhythm sleep disorders in psychiatry.Störungen des Schlaf-Wach-Rhythmus manifestieren sich in Schlafstörungen, Tagesmüdigkeit, kognitiven Leistungseinbußen sowie Stimmungsverschlechterungen. Sie sind bei psychiatrischen Patienten häufig anzutreffen. Dies beruht auf einer engen Beziehung zwischen Funktionsstörungen der inneren Uhr, der Schlafregulation und der psychischen Gesundheit. Mechanismen auf genetischer Ebene der zirkadianen Rhythmusentstehung und Störungen der Neurotransmittersignale können bei beiden Krankheiten involviert sein. Im Weiteren begünstigen sich zirkadiane Störungen und psychische Erkrankungen über ihre Begleitsymptome wie Stress oder soziale Isolation gegenseitig. Aktimetrie zur objektiven Erfassung des Schlaf-Wach-Rhythmus und Melatoninmessungen im Speichel werden eingesetzt, um zirkadiane Schlaf-Wach-Störungen bei psychiatrischen Patienten zu diagnostizieren. Chronobiologische Behandlungsmethoden wie Lichttherapie, Dunkel- und Wachtherapie stabilisieren den zirkadianen Schlaf-Wach-Rhythmus und haben aktivierende, antidepressive oder stimmungsausgleichende Wirkung. Sie unterstützen erfolgreich die Behandlung psychiatrischer Erkrankungen.

Awake fiberoptic intubation seems to continually lose importance in recent years. Alternative options of airway management are coming more and more into the focus of clinical anaesthesia and are moreover advertised specifically for the difficult airway. The concern seems justified that this intubation technique - once the indisputed standard in the management of the anticipated difficult airway - is practised less and less so that especially younger colleagues can hardly gain routine practice. This article aims at counteracting this trend and particularly demonstrates a practical approach. Against this background the equipment is described and tips and tricks are given for execution. The main focus are safety aspects and the success factor of a good topical mucosal anaesthesia, which is of greater importance than a concomitant sedation.

The electroencephalogram (EEG) of wakefulness, sleep, and anaesthesia changes during childhood. Especially marked are the changes during the first year of life. In the second half of the first year, in most children EEG stages can be classified visually and automatically during anaesthesia which are similar to those observed in older children. In the first months of life, the EEG of anaesthesia is less differentiated, but it is still useful in patient monitoring during anaesthesia.

Airway management is a core task for anesthesiologists. Deficiencies in training or equipment as well as fateful complications in this field are responsible for a significant proportion of anesthesia-associated morbidity and mortality. Nowadays there are a variety of advanced technical aids on the market to overcome the difficult airway. Nevertheless, the "cannot intubate cannot ventilate scenario" still occurs and regularly results in poor outcome, such as permanent neurological deficits or even death. Therefore, awake fiberoptic intubation remains the gold standard in the expected difficult airway because when applied correctly this technique never leads to a point where a patient's respiration is compromised as a result of medical measures before a secure airway has been established.

The numbers of awake craniotomies performed worldwide are rising. The technique allows a maximum of brain tumor resection with a minimal risk of functional damage in patients, where the tumor is growing close to functional relevant brain areas. The maximal resection improves the long-term outcome of these patients. For the anaesthetist awake craniotomy can be challenging, because he misses the advantages of general anaesthesia (safe airway, suppressed reflexes), but has to deal with the added risks of brain mapping and cortical stimulation (induction of epileptic insults). After adequate patient selection and intense (psychological) preparation a careful anaesthesiologist will be able to accompany the patient throughout this procedure safe and comfortable. This article describes the anaesthesiological management at Erasmus MC, University Medical Centre Rotterdam, The Netherlands, in detail.

Sleep disorders in early childhood tend to be chronic and almost always a burden for the parents. This study developed and evaluated a multimodal parent training program for children 0.5 to 4 years of age suffering from sleep disorders (Mini-KiSS). We hypothesized that there would be specific improvements following the structured group training (reduction of sleep problems, improvement of parental well-being).The pilot study consisted of a pre-post test design without control group. Participants were n = 17 parents of children 0.5 to 4 years of age with sleep disorders determined according to the ICSD-II. Each of the six sessions was evaluated, and changes were assessed by sleep diary and CBCL. Behavioral and emotional problems of the child were assessed by CBCL, parental well-being, and SCL-90-R.The results showed high acceptance of Mini-KiSS and satisfactory feasibility. Children showed significant improvements of the sleep disturbances such as nightly awakenings as well as sleeping in parents' bed. Furthermore, improvements were found for children's emotional and behavioral problems and for parental well-being, in particular for the depression scale of the mother.This pilot study shows a high acceptance and good feasibility of the multimodal short-time parent-training program Mini-KiSS. Sleep problems were significantly reduced.

Up to 25 % of all acute ischemic strokes (AIS) occur during sleep with the patients or relatives becoming aware of their neurological deficits as they wake up. Because of the unclear time of stroke onset patients with stroke on awakening are usually not considered for acute therapies and excluded from most treatment trials. We give an overview of the published data regarding ischemic wake up strokes (WUS). In particular we focused on baseline characteristics, imaging methods and therapy strategies. Comparing WUS patients and patients with known stroke onset there were no major differences found regarding patient characteristics, etiology, clinical and radiological characteristics. Even though there is no existing gold standard multiparametric neuroimaging (CT; MRI) appears to be helpful for decision making whether to treat a WUS patient with thrombolysis or not. Especially multiparametric MRI which proved to be safe in patients within an extended time window might serve as an adequate diagnostic tool. The results of first pilot studies analyzing treatment of WUS demonstrate that a substantial number of these patients can be treated with IV thrombolysis (IVT) successfully. Large randomized, controlled, prospective clinical trials for patients with WUS are needed to test safety and efficacy of IVT and to evaluate the assumed benefit of multiparametric neuroimaging techniques in this patient group. The results of first pilot studies may be instrumental to help plan and design such trials.

We describe a case of hiccup in an awakening patient. Since there was no success in stopping the hiccup by deepening anaesthesia with Desflurane, we used Propofol 1.3 mg/kg BW as a short acting i.v. anaesthetic with a fast onset to provide early recovery after eliminating hiccup in the awakening patient. Recommendations for the therapy of hiccup range from breathing exercises to the implantation of a phrenic nerve stimulator. The small number of comparable patients and the lack of controlled studies prevent evidence-based recommendations for therapy. Currently patients profit mostly from the exchange of personal experiences.

Especially during monitoring activities or car driving needing high vigilance, episodes of microsleep are extremely dangerous. Microsleep can be described by observing behaviour patterns or electrophysiological parameters. An early recognition of these episodes is desirable. In the automobile industry intensive development is ongoing to register sleepiness and subsequent microsleep during driving to avoid accidents. The monitoring of eyelid frequency and diameter of the pupil (eye tracking) are most promising. Compared with a reference population, the accident risk of patients with sleep-related breathing disorders is more than two-fold higher. But up to now there are no definitive criteria--neither subjective nor objective tests such as, for instance, driving simulators--to predict driving impairment. By means of screening examinations, patients with obstructive sleep apnoea syndrome (OSAS) should be detected because therapy with CPAP normalises the accident rate. A further measure to reduce the risk of accidents is the so-called alertness management where techniques are communicated to detect and avoid sleeping episodes.