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Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.

The application of extracorporeal lung support (ECLS) in patients with acute respiratory distress syndrome is a well-established concept. In patients receiving ECLS therapy, hemodynamic monitoring is often required. However, less is known about the effect of ECLS on hemodynamic measurements. In the present work, the influence of single-site low-flow veno-venous ECLS (LFVV-ECLS) on hemodynamic monitoring by transpulmonary thermodilution (TPTD) was prospectively investigated. Five consecutive patients undergoing single-site LFVV-ECLS for severe hypercapnic respiratory failure were included in this study. For single-site LFVV-ECLS, a 22 Fr twin-port double-lumen cannula was inserted percutaneously into the right jugular vein. Hemodynamic monitoring was performed using the Pulse index Continuous Cardiac Output system. Before ECLS initiation, baseline measurements of cardiac index, systemic vascular resistance, mean arterial pressure, and extravascular lung water (EVLW) were performed. During the first 3 days of ECLS therapy, repeated hemodynamic measurements at different ECLS flow rates were performed. No significant differences were seen in hemodynamic measurements. With respect to EVLW, a significant decrease over the duration of ECLS therapy was observed. This study demonstrates that LFVV-ECLS does not interfere with TPTD. It needs to be further studied if these findings also apply to other ECLS modes.

Der Effekt der intraartikularen (i.a.-)Bupivacaingabe auf die postoperativen Schmerzen nach arthroskopischen Operationen ist bisher vor allem am Kniegelenk untersucht worden; fur arthroskopische Operationen am Huftgelenk gibt es diesbezuglich keine Daten. In der vorliegenden prospektiven, randomisierten, doppelblinden Studie sollte erstmals der Effekt einer i.a.-Gabe von Bupivacain nach arthroskopischen Huftgelenkeingriffen evaluiert werden. Es wurden 26 Patienten in die Studie eingeschlossen: 13 Patienten erhielten nach dem arthroskopischen Eingriff 20 ml 0,25%iges Bupivacain i.a. uber den liegenden Trokar des Operateurs und 13 Patienten 20 ml 0,9%ige NaCl-Losung als Placebo. Postoperativ wurden nach 0,5; 4; 8; 12; 16 und 20 h sowohl die Schmerzintensitat in Ruhe, bei Beugung des Huftgelenks und auch der zusatzliche Piritramidverbrauch erfasst. Weiterhin wurde aus allen erhobenen VAS-Werten fur jeden Patient jeweils ein arithmetischer VAS-Mittelwert in Ruhe und bei Beugung errechnet. In Ruhe zeigte sich eine signifikant niedrigere Schmerzintensitat in der Bupivacaingruppe im Vergleich zur Placebogruppe (17,5 vs. 27,5; p=0,05), die sich bei Beugung noch ausgepragter darstellte (23 vs. 46; p=0,001). Der Piritramidverbrauch war in der Placebogruppe zu allen Zeitpunkten tendenziell, jedoch nicht signifikant hoher. Die i.a.-Gabe von Bupivacain bei arthroskopischen Huftgelenkoperationen reduziert postoperativ vor allem den dynamischen Schmerz und konnte somit ggf. eine fruhzeitigere Mobilisation ermoglichen.

Die Minimierung des perioperativen kardiovaskularen Risikos durch medikamentose Interventionen spielt in der Anasthesie eine wichtige Rolle. So hat z. B. die Therapie mit β-Blockern inzwischen einen festen Stellenwert in der perioperativen anasthesiologischen Behandlung erlangt. In der Literatur gibt es eine zunehmende Fulle an Hinweisen auf einen myokardprotektiven Effekt der volatilen Anasthetika. Dieses Phanomen wird mit dem Begriff der anasthetikainduzierten Prakonditionierung (AP) beschrieben. Tierexperimentelle Daten sind vielfaltig und komplex. Die Mechanismen der anasthetikainduzierten Kardioprotektion wurden eingehend untersucht, sind aber letztlich nicht abschliesend geklart. Auch erste klinische Daten belegen einen protektiven Effekt der inhalativen Anasthetika anhand von myokardialen Funktions- und Schadigungsparametern. Daher stellt sich fur den klinisch tatigen Anasthesisten die Frage einer praktischen Relevanz fur die Narkosefuhrung bei Patienten mit entsprechendem Risikoprofil. Die vorliegende Arbeit gibt einen Uberblick uber die derzeitigen wissenschaftlichen Ergebnisse mit einer Fokussierung auf die Mechanismen der anasthesiologischen Prakonditionierung und auf klinische Untersuchungen.

Viele in der Anasthesie verwendeten Pharmaka beeinflussen die cholinerge Erregungsubertragung; somit sind Cholinesterasehemmer Teil des pharmakologischen Repertoires des Fachgebietes. Neben der bisher klinisch etablierten Anwendung zur Antagonisierung der neuromuskularen Blockade und der Therapie des zentral anticholinergen Syndroms (ZAS) lassen die Ergebnisse von klinischen Studien und Fallberichten auch vorteilhafte Indikationen in der Therapie des postoperativen Kaltezitterns sowie der Intoxikations- und Delirbehandlung erkennen. Analgetische Wirkungen von Cholinesterasehemmern sind ebenfalls bekannt. Die vorliegende Arbeit soll die physiologischen und pharmakologischen Grundlagen zusammenfassen und einen aktuellen Uberblick uber die Einsatzmoglichkeiten dieser Substanzgruppe vermitteln.

Molecular biology has revolutionized medicine by increasing our understanding of the pathophysiological mechanisms of disease and the ability to assess genetic risk. Individual differences in disease manifestation and course in intensive care medicine often cannot be explained by known phenotypic risk factors alone. Recent data suggest an association between specific genotypes and the risk of adverse clinical outcomes. This includes inflammatory responses (i.e. TNF-alpha, Il-10), infectious diseases such as pneumonia or meningitis, sepsis, ARDS, as well as the mortality of critically injured patients (polytrauma, severe brain trauma). Continued identification of such allotypes and haplotypes may not only provide insight as to why the response to treatment varies amongst individuals in the intensive care unit, but also may potentially decrease morbidity and mortality through improved risk assessment and the administration of prophylactic therapy.

Melagatran is a direct inhibitor of thrombin and-like its oral prodrug ximelagatran-a newly developed dipetide with high antithrombotic efficacy. They present a linear dose-response, a short plasma half-life and the therapeutic range may be advantageous compared with classic anticoagulants such as heparins or vitamin K antagonists. The results of clinical studies for prevention and treatment of thromboembolic complications are encouraging. The use of melagatran and ximelagatran will gain significance in the perioperative management, thus being of particular importance for anaesthesiology and critical care medicine in the near future.

The intraoperative application of extracorporeal lung support devices during thoracic surgical procedures represents a modern concept with promising results. So far, pumpless extracorporeal interventional lung assist and veno-venous or veno-arterial extracorporeal membrane oxygenation via dual cannulation were utilized for complete or partial lung support throughout the surgical procedure. We report the initial intraoperative application of low-flow singular double-lumen veno-venous-extracorporeal membrane oxygenation for extracorporeal lung support during lung resections in patients with severely impaired preoperative pulmonary function. In our hands, this novel concept contributed to the safe performance of complex surgery in pulmonary compromised patients avoiding the possible complications of other forms of extracorporeal support.