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Background: Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies., Objective: The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany., Method: To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies., Results: In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis., Discussion: Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Importance: Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality., Objective: To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality., Design, Setting, and Participants: This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours., Interventions: A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol., Main Outcomes and Measures: The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay., Results: Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly., Conclusions and Relevance: Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days., Trial Registration: ClinicalTrials.gov Identifier: NCT04016454.

Background: The use of perioperative checklists has generated a growing body of evidence pointing toward reduction of mortality and morbidity, improved compliance with guidelines, reduction of adverse events, and improvements in human factor-related areas. Usual quality management metrics generally fall short in assessing compliance with their perioperative application. Our study assessed application attitudes and compliance with safety measures centered around the World Health Organization (WHO) "Safe Surgery Saves Lives" campaign as perceived by anesthesia professionals in Germany., Methods: Three hundred sixteen physicians and nurses participated in our cross-sectional survey, and 304 completed all 35 questions., Results: Only 59.5% of participants had knowledge of the theoretical framework behind the WHO campaign. During the "sign-in," patient ID and surgical site were checked in 99.6% and 95.1% as recommended by the WHO. Allergies were addressed by 89.2%, expected difficult airway by 65.7%, and the availability of blood products by 70.5%. A total of 84.9% of participants advocated for the time-out to include all persons present in the operating room, which was the case in 57.0%. A total of 40.8% stated that the time-out was only performed between anesthetist and surgeon; in 17.0% of cases, the patient was simultaneously draped and/or surgically scrubbed. No significant differences between hospital types were observed., Conclusions: Our study paints a heterogeneous picture of the implementation, usage, and safety attitudes concerning the Safe Surgery Checklist as promoted by the WHO. The lack of standardized execution and team-mindedness can be taken as further evidence for the importance of interdisciplinary training focusing on human factors, communication, and collaboration rather than the mere implementation by decree., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postdural puncture headache (PDPH) occurs in up to 11% of patients after spinal anesthesia and in more than 80% after dural perforation upon epidural anesthesia. It represents a severe anesthesiological complication in obstetric patients. If conservative medication measures do not result in a timely relief of symptoms, the current guidelines recommend the early implementation of an epidural blood patch; however, although performing an epidural blood patch is effective to treat PDPH, potential side effects include neurological complications, spinal hematoma and infections. Assumed to reduce cerebral vasodilatation as a potential pathophysiological driver of PDPH, the transnasal block of the sphenopalatine ganglion with local anesthetics is discussed as an alternative approach., Methods: In this case study a modification of this technique is reported using a mucosal atomization device (MAD) for off-label nasal administration of lidocaine in two obstetric patients suffering from PDPH. Up to now there is no experience with this modified technique in obstetric anesthesiology., Results: The first patient (25-year-old secundigravida, body mass index [BMI] 54.7 kg/m 2 ) displayed a pronounced PDPH with nausea and vomiting during the first day after a cesarean section under spinal anesthesia (3 attempts). The second patient (32-year-old tertiagravida, BMI 27.3 kg/m 2 ) was readmitted to hospital due to PDPH 4 days after a natural birth under epidural anesthesia. Whereas conservative measures and therapeutic attempts with nonopioid analgesics and caffeine did not result in a sufficient treatment success, intranasal lidocaine administration via a MAD led to an immediate and persisting symptom relief. Both patients could be discharged from hospital after 24 h of surveillance and did not report any relevant side effects of the lidocaine administration., Conclusion: The described noninvasive and simple procedure represents a valuable addition to previously known treatment options for PDPH and a potential alternative to an epidural blood patch in obstetric patients with PDPH. Prospective studies are needed to validate the findings.

Surgical oncology makes up an essential part of all surgical procedures performed. Anesthetists can contribute significantly to the treatment success by a thorough pre-operative assessment of patients. Cancer patients are not only in general at higher risk for thrombosis and anemia but can also suffer from a plethora of adverse effects from modern cancer drugs. Hence, it is the responsibility of anesthetists to gather knowledge about the changes in organ systems due to the rapidly increasing list of anti-cancer agents. This article serves as a review from anesthetists to anesthetists conveying the important aspects for taking a comprehensive patient history as well as summarizing the adverse events of major drug classes currently in use in oncology., Competing Interests: Die Autorinnen/Autoren geben an, dass keine Interessenkonflikte bestehen., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Human factors research has identified mental models as a key component for the effective sharing and organization of knowledge. The challenge lies in the development and application of tools that help team members to arrive at a shared understanding of a situation. The aim of this study was to assess the influence of a semi-structured briefing on the management of a simulated airway emergency., Methods: 37 interprofessional teams were asked to perform a simulated rapid-sequence induction in the simulator. Teams were presented with a "cannot ventilate, cannot oxygenate" scenario that ultimately required a cricothyroidotomy. Study group (SG) teams were asked to perform a briefing prior to induction, while controls (CG) were asked to perform their usual routine., Results: We observed no difference in the mean time until cricothyroidotomy (SG 8:31 CG 8:16, p = 0.36). There was a significant difference in groups' choice of alternative means of oxygenation: While SG teams primarily chose supraglottic airway devices, controls initially reverted to mask ventilation (p = 0.005). SG teams spent significantly less time with this alternative airway device and were quicker to advance in the airway algorithm., Conclusions: Our study addresses effects on team coordination through a shared mental model as effected by a briefing prior to anesthesia induction. We found measurable improvements in airway management during those stages of the difficult airway algorithm explicitly discussed in the briefing. For those, time spent was shorter and participants were quicker to advance in the airway algorithm.

Because of new surgical techniques, advanced monitoring modalities and improvements in perioperative care, perioperative mortality and morbidity have been significantly reduced in the last decades; however, patients still suffer from high perioperative mortality and morbidity, especially those with pre-existing cardiovascular diseases. Not only perioperative myocardial infarction but also myocardial injury after non-cardiac surgery, which presents without clinical symptoms, is associated with an adverse outcome. Patients at risk require particular interdisciplinary attention throughout the perioperative phase. The premedication visit is of particular importance. In addition to a thorough patient medical history and physical assessment, the perioperative handling of the patient's pre-existing medication and possible necessity for further preoperative tests should be verified. If necessary and where possible, optimization of the patient's state of health can be planned together with other disciplines. It is the anesthesiologist's responsibility to optimally guide and support patients with pre-existing cardiovascular diseases through the entire surgical procedure. This review summarizes perioperative interventions that have an influence on patient mortality and morbidity and evaluates the underlying evidence. This covers the perioperative handling of cardioprotective medication, choice of the anesthetic regimen, blood pressure management and transfusion regimens. Furthermore, this review highlights recent findings, e.g. perioperative reloading with statins and short-term preoperative initiation of beta blockers. The pros and cons of thoracic epidural anesthesia in patients with an elevated cardiovascular risk are discussed. Not only intraoperative hypotension should be of concern to anesthesiologists but also postoperative hypotension can have a deleterious impact on the outcome. This is relevant in the time period when a significant proportion of patients have already left the monitoring ward. The recently published recommendations by the World Health Organization concerning perioperative hyperoxia might not be beneficial for patients with an elevated cardiovascular risk. Finally, the treatment options for perioperative cardiovascular events are explained and an algorithm for handling of patients with perioperative myocardial injury without clinical ischemic symptoms is suggested (myocardial injury after non-cardiac surgery).

Background: The Human Factors Analysis and Classification System (HFACS) was developed as a practical taxonomy to investigate and analyse the human contribution to accidents and incidents. Based on Reason's "Swiss Cheese Model", it considers individual, environmental, leadership and organizational contributing factors in four hierarchical levels. The aim of this study was to assess the applicability of a modified HFACS taxonomy to incident reports from a large, anonymous critical incident database with the goal of gaining valuable insight into underlying, more systemic conditions and recurring schemes that might add important information for future incident avoidance., Methods: We analysed 50 reports from an anonymous, anaesthesiologic, single-centre Critical Incident Reporting System using a modified HFACS-CIRS taxonomy. The 19 HFACS categories were further subdivided into a total of 117 nanocodes representing specific behaviours or preconditions for incident development., Results: On an individual level, the most frequent contributions were decision errors, attributed to inadequate risk assessment or critical-thinking failure. Communication and Coordination, mostly due to inadequate or ineffective communication, was contributory in two-thirds of reports. Half of the reports showed contributory complex interactions in a sociotechnical environment. Ratability scores were noticeably lower for categories evaluating leadership and organizational influences, necessitating careful interpretation., Conclusions: We applied the HFACS taxonomy to the analysis of CIRS reports in anaesthesiology. This constitutes a structured approach that, especially when applied to a large data set, might help guide future mitigation and intervention strategies to reduce critical incidents and improve patient safety. Improved, more structured reporting templates could further optimize systematic analysis., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: In the past, anaesthetic breathing circuits were identified as a source of pathogen transmission. It is still debated, whether breathing circuits combined with breathing system filters can be safely used for more than 1 day. The aim of this study was to evaluate the transmission risk of bacteria and also viruses via breathing circuits after extended use., Methods: The inner and outer surface of 102 breathing circuits used for 1 day and of 101 circuits used for 7 days were examined for bacteria and viruses. Additionally, 10 and 20 breathing circuits each were examined after use on patients with pulmonary virus infection and with multidrug-resistant organism (MDRO) colonisation/infection respectively. Bacteria were detected by standard microbiological procedures; PCR techniques were applied for herpes simplex virus, cytomegalovirus, influenza, parainfluenza and respiratory syncytial virus., Results: Endoluminal bacterial contamination of breathing circuits remained unchanged after 7-day vs. 1-day use (5.9% vs. 7.8%) [CI95%: -0.0886-0.0506, pnon-inferiority 0.0260]. Only outside surface contamination with bacteria belonging to environmental species or human flora increased (16.8 vs. 6.9%) [CI 95%: 0.0118 - 0.1876, pnon-inferiority 0.8660]. Viruses occurred on the patient side, but not in breathing circuits. No MDRO occurred in the 20 circuits after use on patients harbouring such germs., Conclusion: Endoluminal contamination of breathing circuits with bacteria did not increase after extended use. No viruses were detected in the breathing circuits using filters. Based on our results, the extended use of ABC without exceptions appears safe, if a high level of anaesthesia workplace cleaning is secured., (© 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: In the hospital, human resource planning has to consider the needs and preferences of personnel and planners as well as the financial interest of the hospital. Additionally, staff planning has become more complex due to a growing number of part-time doctors as well as a variety of working shifts., Objectives: The aim of the study was to describe existing human resource planning in German anesthesiology departments. Furthermore, we evaluated existing software solutions supporting human resource planning., Materials and Methods: Anesthesiology departments of German university hospitals were enrolled in the study. The aspects covered were tools and time needed for planning, amount of conflicts while planning, components of the software solutions and the efficiency and satisfaction according to the users. This was evaluated for short-, intermediate- and long-term planning. Two groups were compared: departments with and without software exchanging information among the three planning periods., Results: Out of 35 university anesthesiology departments, 23 took part in the survey. On average they employed 105.8 ± 27.8 doctors who had to cover 13.5 ± 6.3 different shifts during a weekday. Personnel planning is mostly done by senior physicians. In some departments, other staff, such as residents and junior doctors, were involved as well. Software that exchanged information between short-, intermediate- and long-term planning was used in 53 % of the departments (12 out of 23). Five departments used commercially available planning software: Polypoint Deutschland (PolypointDeutschland), Atoss (Atoss AG) and SP Expert (Interflex Datensysteme). The time needed for short-term planning was slightly reduced in the exchanging software group. No difference was shown for the intermediate planning period. The use of this software led to a slight reduction in planning conflicts and increased the self-estimated efficiency of the users (p = 0.02). Throughout all groups, the major complaint was missing interfaces, for example between the software and human resources department. The ideal planning software should reduce time needed for planning and prevent planning conflicts according to the interviewed physicians. Furthermore it should be flexible and transparent for all involved staff., Conclusions: This study analyzed structures established in human resource planning in the anesthesiology departments for the first time. Time for planning varies significantly in comparable departments indicating suboptimal processes. Throughout Germany, the requirements for human resources planning are similar; for example, the software should integrate all aspects of HR planning. Different approaches are under evaluation but so far no software solution has prevailed. The used solutions vary substantially and therefore a comparison is difficult. There is no software solution with wide adoption.

Background: Laryngeal mask insertion (LMI) represents a fundamental skill for anesthesiologists in routine management as well as in difficult airway situations. This study aimed to evaluate the time needed by first year anesthesiology residents to perform 40 LMIs and assessed the associated success rates and the number of attempts needed for successful LMI., Methods: This prospective single center study evaluated the number of work days, the success rate and the attempts needed for successful LMI (LMA ProSeal™) in consecutive blocks of five LMI procedures and the related difficulties and complications., Results: From 2007 to 2010 a total of 10 anesthesiology resident physicians were evaluated consecutively. These residents needed a mean of 18.3 ± 4.1 (mean ± standard deviation) working days to successfully perform 40 LMIs. The LMI success rate after the first 5 LMIs increased steadily up to the results after 40 LMIs per resident (LMI success rate within 1 attempt 72 versus 86 %, p = 0.09, LMI success rate within all LMI attempts 74 versus 96 %, p = 0.001). The mean number of attempts required until successful LMI decreased from 1.45 ± 0.82 after the first 5 LMIs to 1.16 ± 0.37 after 40 LMIs (p = 0.03). The most common difficulties associated with unsuccessful LMI by residents that led to handing over to an experienced colleague were small oral aperture (9.8 %), short thick neck, large tongue, blood/mucus in the mouth or throat (each 7.3 %) and retrognathy (4.9 %)., Conclusions: The increasing LMI success rate and the decreasing rate of LMI attempts for successful airway management correlated to a learning curve and development of LMI dexterity over time.

Surgery and anesthesiology have always been closely connected. Within the increasing complexity of therapies and technical capabilities both subjects overlap in certain areas. This article deals with the question whether anesthesiology is acting as a partner or competitor in the cooperation with the various operative specialties. In several studies it has been shown that the outcome of surgical patients can be improved by communication and interaction with anesthesiology and that forming multidisciplinary teams will be highly beneficial for patients in intensive care units.

Abstract Background Although a device is needed to continuously measure blood glucose levels within an intensive care setting, and several large-scale prospective studies have shown that patients might benefit from intensive insulin, potassium, or glucose therapy during intensive care, no devices are currently available to continuously assess blood glucose levels in critically ill patients. We conceived the study described here to evaluate the clinical use of the Continuous Glucose Monitor (CGM) performed via a central vein, and to determine the impact of phenomena, such as drift and shift, on the agreement between the CGM and a RAPIDLab® 1265 blood gas analyser (BGA). Methods/design In the CONTinuous ASSessment of blood GLUcose (CONTASSGLU) study, up to 130 patients under intensive care will be fitted with the CGM, an ex vivo device that continuously measures blood glucose and lactate levels. Readings from the device taken 8 h after initial placement and calibration will be compared with values measured by a BGA. For this study, we chose the BGA as it is an established standard point-of-care device, instead of the devices used in certified central laboratories. Nevertheless, we will also independently compare the results from the point-of-care BGA with those determined by a central laboratory-based device. Blood samples will be collected from each patient from the same site in which the CGM will measure blood glucose. Consequently, each participant will serve as their own control, and no randomisation is necessary. The 95% limits of agreement and the corresponding confidence intervals will be calculated and compared with a prespecified clinically acceptable relative difference of 20%. Discussion Several attempts have been made to develop a device to continuously measure blood glucose levels within an intensive care setting or to use the devices that were originally designed for diabetes management, as several of these devices are already available. However, none of these devices were successful in intensive care settings. CONTASSGLU may well bridge this gap by confirming the ability of the CGM to continuously measure blood glucose levels in intensive care settings. Trial registration ClinicalTrials.gov NCT01580176