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Observing modern decompression protocols alone cannot fully prevent diving injuries especially in repetitive diving. Professional audio Doppler bubble measurements are not available to sports scuba divers. If those non-professionals were able to learn audio Doppler self-assessment for bubble grading, such skill could provide significant information on individual decisions with respect to diving safety. We taught audio Doppler self-assessment of subclavian and precordial probe position to 41 divers in a 45-min standardized, didactically optimized training. Assessment before and after air dives within sports diving limits was made through 684 audio Doppler measurements in dive-site conditions by both trained divers and a medical professional, plus additional 2D-echocardiography reference. In all dives (average maximum depth 22 m; dive time 44 min), 33% of all echocardiography measurements revealed bubbles. The specificity of audio bubble detection in combination of both detection sites was 95%, and sensitivity over all grades was 40%, increasing with higher bubble grades. Dive-site audio-Doppler-grading underestimated echo-derived bubble grades. Bubble detection sensitivity of audio Doppler self-assessments, compared to an experienced examiner, was 62% at subclavian and 73% at precordial position. 6 months after the training and 4.5 months after the last measurement, the achieved Doppler skill level remained stable. Audio Doppler self-assessment can be learned by non-professionals in a single teaching intervention. Despite accurate bubble grading is impossible in dive-site conditions, relevant high bubble grades can be detected by non-professionals. This qualitative information can be important in self-evaluating decompression stress and assessing measures for increased diving safety.

Objective To determine whether a history of cerebrovascular disease (CVD) increases risk of severe coronavirus disease 2019 (COVID-19). Methods In a retrospective multicenter study, we retrieved individual data from in-patients treated March 1 to April 15, 2020 from COVID-19 registries of three hospitals in Saxony, Germany. We also performed a systematic review and meta-analysis following PRISMA recommendations using PubMed, EMBASE, Cochrane Library databases and bibliographies of identified papers (last search on April 11, 2020) and pooled data with those deriving from our multicenter study. Of 3762 records identified, 11 eligible observational studies of laboratory-confirmed COVID-19 patients were included in quantitative data synthesis. Risk ratios (RR) of severe COVID-19 according to history of CVD were pooled using DerSimonian and Laird random effects model. Between-study heterogeneity was assessed using Cochran’s Q and I2-statistics. Severity of COVID-19 according to definitions applied in included studies was the main outcome. Sensitivity analyses were conducted for clusters of studies with equal definitions of severity. Results Pooled analysis included data from 1906 laboratory-confirmed COVID-19 patients (43.9% females, median age ranging from 39 to 76 years). Patients with previous CVD had higher risk of severe COVID-19 than those without [RR 2.07, 95% confidence interval (CI) 1.52–2.81; p p p p Conclusion A history of CVD might constitute an important risk factor of unfavorable clinical course of COVID-19 suggesting a need of tailored infection prevention and clinical management strategies for this population at risk.

Der Begriff der Anaphylaxie beschreibt die schwerste Verlaufsform einer allergischen Reaktion. Dabei handelt es sich um eine akute, systemisch ablaufende Immunreaktion auf Substanzen, gegen die in den meisten Fallen eine vorherige Sensibilisierung stattgefunden hat. Eine anaphylaktische Reaktion kann alle Organsysteme betreffen und potenziell lebensbedrohlich sein. Zu den ersten Symptomen zahlen beispielsweise Dyspnoe, Hypotension, Tachykardie oder das Entstehen eines Exanthems. In kurzester Zeit kann das Vollbild eines anaphylaktischen Schocks auftreten. Vor allem perioperativ ist eine Anaphylaxie nicht immer eindeutig zu identifizieren. Umso wichtiger ist die Kenntnis der moglichen Trigger einer allergischen Reaktion im OP. Eine schnelle Identifikation des Krankheitsbildes und die sofortige Einleitung der Behandlung sind dann essenziell.

Zusammenfassung Hintergrund Vor dem Hintergrund einer stetig zunehmenden Gesundheitsgefährdung durch multiresistente Erreger spielt neben der Bevölkerungsaufklärung, der Fachkenntnis und der Fortbildung der Ärztinnen und Ärzte auch deren Selbstsicherheit eine Schlüsselrolle in der klinischen Entscheidungsfindung. Ziel der Arbeit Die Analyse soll den Einfluss der Fachrichtung auf Unterschiede der Selbstsicherheit im Umgang mit Antibiotika und in der Selbsteinschätzung des eigenen Wissens untersuchen. Methodik Im Jahr 2015 wurden 1061 Ärztinnen und Ärzte der Fachrichtungen Innere Medizin, Allgemeinchirurgie, Gynäkologie und Urologie mithilfe des MR2 (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria)-Surveys über ihre Einstellung und ihr Wissen zu Antibiotika und multiresistenten Erregern befragt. Ein ähnlicher Fragebogen wurde 2017 an 1268 Ärzte der Anästhesiologie versendet. Es wurden vier Fragen zur eigenen Sicherheit in der Anwendung von Antibiotika und elf Fragen zur Einschätzung des eigenen Wissens über multiresistente Erreger und rationale Antibiotikatherapie ausgewertet. Der Einfluss der Fachrichtung auf diese Items wurde mittels einer logistischen Regressionsanalyse, eines „chi square tests“ und des Kruskal-Wallis-Tests untersucht. Ergebnisse Die Rücklaufquoten betrugen 43 % (456/1061) und 56 % (705/1268). Im Jahr vor der Umfrage haben 44 % der Nicht-Anästhesisten und 57 % der Anästhesisten keine Fortbildung zu Inhalten des Antibiotic Stewardships besucht. Im Hinblick auf die Selbstsicherheit im Umgang mit Antibiotika zeigten sich Anästhesisten (Mittelwert ± Standardabweichung: 2,53±0,54) signifikant unsicherer als ihre Kollegen (Innere Medizin: 3,10±0,50; Chirurgie: 2,97±0,44; Gynäkologie: 3,12±0,42; Urologie: 3,15±0,44); dies gilt sowohl für die nicht-adjustierten (alle p Schlussfolgerungen Anästhesisten zeigten eine signifikant geringere Selbstsicherheit im Umgang mit Antibiotika als ihre Kollegen aus anderen Fachrichtungen. Fortbildungen zur rationalen Verordnung von Antibiotika waren mit einer höheren Handlungssicherheit assoziiert, so dass eine Verankerung in den jeweiligen Weiterbildungsinhalten zu diskutieren ist.

Background Mechanical ventilation with variable tidal volumes (VT) may improve lung function and reduce ventilator-induced lung injury in experimental acute respiratory distress syndrome (ARDS). However, previous investigations were limited to less than 6 h, and control groups did not follow clinical standards. We hypothesised that 24 h of mechanical ventilation with variable VT reduces pulmonary inflammation (as reflected by neutrophil infiltration), compared with standard protective, nonvariable ventilation. Methods Experimental ARDS was induced in 14 anaesthetised pigs with saline lung lavage followed by injurious mechanical ventilation. Pigs (n=7 per group) were randomly assigned to using variable VT or nonvariable VT modes of mechanical ventilation for 24 h. In both groups, ventilator settings including positive end-expiratory pressure and oxygen inspiratory fraction were adjusted according to the ARDS Network protocol. Pulmonary inflammation (primary endpoint) and perfusion were assessed by positron emission tomography using 2-deoxy-2-[18F]fluoro-d-glucose and 68Gallium (68Ga)-labelled microspheres, respectively. Gas exchange, respiratory mechanics, and haemodynamics were quantified. Lung aeration was determined using CT. Results The specific global uptake rate of 18F-FDG increased to a similar extent regardless of mode of mechanical ventilation (median uptake for variable VT=0.016 min−1 [inter-quartile range, 0.012–0.029] compared with median uptake for nonvariable VT=0.037 min−1 [0.008–0.053]; P=0.406). Gas exchange, respiratory mechanics, haemodynamics, and lung aeration and perfusion were similar in both variable and nonvariable VT ventilatory modes. Conclusion In a porcine model of ARDS, 24 h of mechanical ventilation with variable VT did not attenuate pulmonary inflammation compared with standard protective mechanical ventilation with nonvariable VT.

BACKGROUND As a part of the German academic system the scientific habilitation is a significant individual qualification in research and teaching. In a pilot project, we recently reported the number of habilitations in anesthesiology, visceral surgery, gynecology and internal medicine. Here, we analyze habilitations from 13 additional clinical specialties. METHODS Habilitations in clinical specialties published in the German Medical Journal (Dtsch Arztebl) between 2010 and 2017 were quantitatively analyzed. For data validation, the dean offices of all German medical schools were requested to forward all accomplished habilitations. The percentage of women and the numbers with respect to the specialty were analyzed for each university hospital. Data are presented as medians (interquartile ranges). RESULTS In this study, 2,264 accomplished habilitations were analyzed. Annually, 45 (36-56) habilitations were reported in orthopedic/trauma surgery, 40 (36-48) in radiology and 37 (29-46) in neurology, while the medians in the other analyzed specialties were lower. The highest percentage of women earning a habilitation degree was reported for pediatrics (37 %), dermatology (33 %), and ophthalmology (32 %). CONCLUSIONS Here, the output of completed habilitations from 13 medical specialties was analyzed for each German medical school. As a habilitation stands for a sustainable scientific contribution, this study may help to identify further career development needs for junior and for female scientists.

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as V(T) of 8 ml kg(−1) or less predicted bodyweight (PBW). A V(T) was deemed ‘default’ if the set V(T) was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default V(T) was often set, both in women and men; mode V(T) was 500 ml. Median [IQR] V(T) was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg(−1) PBW, P*** < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P*** < 0.001]. In the mediation analysis, patients’ height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default V(T). CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher V(T) than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Background Dislocation of catheters within the tissue is a challenge in continuous regional anesthesia. A novel self-coiling catheter design is available and has demonstrated a lower dislocation rate in a cadaver model. The dislocation rate and effect on postoperative pain of these catheters in vivo has yet to be determined and were the subjects of this investigation. Methods After ethics committee approval 140 patients undergoing elective distal lower limb surgery were enrolled in this prospective randomized controlled trial. Preoperatively, patients were randomly assigned and received either the conventional (n = 70) or self-coiling catheter (n = 70) for ultrasound-guided popliteal sciatic nerve block in short axis view and by the in-plane approach from lateral to medial. The primary outcome was pain intensity after surgery and on the following three postoperative days. Secondary outcomes investigated were dislocation rate in situ determined by sonography, catheter movement visible from outside, opioid consumption as well as leakage at the puncture site. Results All catheters were successfully inserted. The study population of self-coiling catheters had significantly lower mean numeric rating scale values than the reference cohort on the first (p = 0.01) and second postoperative days (p p = 0.04, p = 0.03 and p = 0.04, respectively). Conclusion The self-coiling catheter offers a better postoperative pain control and a lower dislocation rate within the tissue when blocking the popliteal sciatic nerve compared to a conventional catheter. Further trials in large patient cohorts are warranted to investigate the potential beneficial effects of self-coiling catheters for other localisations and other application techniques. Trial registration The trial was registered at German Clinical Trials Register (DRKS) on 08/04/2020 (DRKS00020938, retrospectively registered).

Objectives To determine the impact of positive end-expiratory pressure during mechanical ventilation with and without spontaneous breathing activity on regional lung inflammation in experimental nonsevere acute respiratory distress syndrome. Design Laboratory investigation. Setting University hospital research facility. Subjects Twenty-four pigs (28.1-58.2 kg). Interventions In anesthetized animals, intrapleural pressure sensors were placed thoracoscopically in ventral, dorsal, and caudal regions of the left hemithorax. Lung injury was induced with saline lung lavage followed by injurious ventilation in supine position. During airway pressure release ventilation with low tidal volumes, positive end-expiratory pressure was set 4 cm H2O above the level to reach a positive transpulmonary pressure in caudal regions at end-expiration (best-positive end-expiratory pressure). Animals were randomly assigned to one of four groups (n = 6/group; 12 hr): 1) no spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure - 4 cm H2O, 2) no spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure + 4 cm H2O, 3) spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure + 4 cm H2O, 4) spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure - 4 cm H2O. Measurements and main results Global lung inflammation assessed by specific [F]fluorodeoxyglucose uptake rate (median [25-75% percentiles], min) was decreased with higher compared with lower positive end-expiratory pressure both without spontaneous breathing activity (0.029 [0.027-0.030] vs 0.044 [0.041-0.065]; p = 0.004) and with spontaneous breathing activity (0.032 [0.028-0.043] vs 0.057 [0.042-0.075]; p = 0.016). Spontaneous breathing activity did not increase global lung inflammation. Lung inflammation in dorsal regions correlated with transpulmonary driving pressure from spontaneous breathing at lower (r = 0.850; p = 0.032) but not higher positive end-expiratory pressure (r = 0.018; p = 0.972). Higher positive end-expiratory pressure resulted in a more homogeneous distribution of aeration and regional transpulmonary pressures at end-expiration along the ventral-dorsal gradient, as well as a shift of the perfusion center toward dependent zones in the presence of spontaneous breathing activity. Conclusions In experimental mild-to-moderate acute respiratory distress syndrome, positive end-expiratory pressure levels that stabilize dependent lung regions reduce global lung inflammation during mechanical ventilation, independent from spontaneous breathing activity.

Introduction: Recent studies linked coronavirus disease 2019 (COVID-19) to thromboembolic complications likely mediated by increased blood coagulability and inflammatory endothelial impairment. Objective: We aimed to assess the risk of acute stroke in patients with COVID-19 related to clinical severity of the disease. Methods: We conducted an observational multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we performed a systematic review using PubMed/MEDLINE, EMBASE, Cochrane Library and bibliographies of identified articles following PRISMA guidelines including data from observational studies of acute stroke in COVID-19 patients. Data was extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RR) and 95% confidence intervals (95%CIs) for acute stroke related to COVID-19 severity using random effects model. Between-study heterogeneity was assessed using Cochran’s Q and I 2 -statistics. PROSPERO identifier : CRD42020187194. Results: Of 165 patients hospitalized for COVID-19 (49.1% males, median age 67 [57-79], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95%CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Among 741 pooled COVID-19 patients overall stroke rate was 2.9% (95%CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR 4.12, 95%CI 1.7-10.25; p=0.002) with no evidence of heterogeneity (I 2 =0%, p=0.82). Conclusions: Synthesized analysis of data from our multicenter study and previously published cohorts demonstrate that severity of COVID-19 is associated with an increased risk of acute stroke, underscoring the necessity of neurological monitoring in patients infected with SARS-CoV-2.

Background Continuous external negative pressure (CENP) during positive pressure ventilation can recruit dependent lung regions. We hypothesised that CENP applied regionally to the thorax or the abdomen only, increases the caudal end-expiratory transpulmonary pressure depending on positive end-expiratory pressure (PEEP) in lung-injured pigs. Eight pigs were anesthetised and mechanically ventilated in the supine position. Pressure sensors were placed in the left pleural space, and a lung injury was induced by saline lung lavages. A CENP shell was placed at the abdomen and thorax (randomised order), and animals were ventilated with PEEP 15, 7 and zero cmH2O (15 min each). On each PEEP level, CENP of − 40, − 30, − 20, − 10 and 0 cmH2O was applied (3 min each). Respiratory and haemodynamic variables were recorded. Electrical impedance tomography allowed assessment of centre of ventilation. Results Compared to positive pressure ventilation alone, the caudal transpulmonary pressure was significantly increased by CENP of ≤ 20 cmH2O at all PEEP levels. CENP of – 20 cmH2O reduced the mean airway pressure at zero PEEP (P = 0.025). The driving pressure decreased at CENP of ≤ 10 at PEEP of 0 and 7 cmH2O (P < 0.001 each) but increased at CENP of – 30 cmH2O during the highest PEEP (P = 0.001). CENP of – 30 cmH2O reduced the mechanical power during zero PEEP (P < 0.001). Both elastance (P < 0.001) and resistance (P < 0.001) were decreased at CENP ≤ 30 at PEEP of 0 and 7 cmH2O. Oxygenation increased at CENP of ≤ 20 at PEEP of 0 and 7 cmH2O (P < 0.001 each). Applying external negative pressure significantly shifted the centre of aeration towards dorsal lung regions irrespectively of the PEEP level. Cardiac output decreased significantly at CENP -20 cmH2O at all PEEP levels (P < 0.001). Effects on caudal transpulmonary pressure, elastance and cardiac output were more pronounced when CENP was applied to the abdomen compared with the thorax. Conclusions In this lung injury model in pigs, CENP increased the end-expiratory caudal transpulmonary pressure. This lead to a shift of lung aeration towards dependent zones as well as improved respiratory mechanics and oxygenation, especially when CENP was applied to the abdomen as compared to the thorax. CENP values ≤ 20 cmH2O impaired the haemodynamics.

Purpose Intraoperative detection of intrahepatic lesions can be demanding. The use of preoperative contrast-enhanced magnetic resonance imaging (MRI) or computer tomography (CT) combined with intraoperative ultrasound of the liver is state of the art. Near totally regressed colorectal liver metastases (CRLM) after neoadjuvant chemotherapy or nodules in severely altered liver tissue as steatosis or cirrhosis are often hard to detect during the operative procedure. Especially differentiation between benign atypical nodules and malignant tumors can be very difficult. The intraoperative use of contrast-enhanced ultrasound or intraoperative navigation are helpful tools. However, both methods show relevant limitations. The use of intraoperative MRI (ioMRI) can overcome this problem. Relevant structures can be marked within the operative site or immediate control of complete tumor resection can be achieved. This might allow immediate surgical optimization in case of failure. Methods We report the intraoperative application of ioMRI in a case of a 61-year-old male patient suffering from rectal cancer with 10 synchronous bilobar CRLM who was treated stepwise by multimodal treatment and staged hepatectomy. Intraoperative contrast-enhanced MRI of the liver was used during completion procedure of an extended right hemihepatectomy performed as “Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)”. Results ioMRI provided excellent images and showed absence of liver metastases in the liver remnant. Procedure of ioMRI was safe, fast and feasible. Conclusion To the best of our knowledge, we describe the first case of intraoperative application of a contrast-enhanced MRI during open liver surgery at the University Hospital of Dresden.

ZusammenfassungIm Gegensatz zur präklinischen Notfallmedizin existieren in Deutschland bis heute keine vergleichbaren fest etablierten Strukturen oder gesetzliche Vorgaben zur Aufbau- und Ablauforganisation sowie Personalqualifikation und Ausstattung der innerklinischen Notfallversorgung. Bei perioperativen Patienten treten unerwartete Komplikationen auf Normalstation jedoch relativ häufig auf. Oft sind bereits Stunden vor einem möglichen kritischen Ereignis Warnzeichen für eine Verschlechterung zu erkennen, wobei diese zu oft unbemerkt bleiben und es im Verlauf zu vermeidbaren schwerwiegenden Komplikationen oder Herz-Kreislauf-Stillständen kommen kann. Zur Verbesserung der innerklinischen Versorgungsstruktur und zur Vermeidung von innerklinischen Herz-Kreislauf-Stillständen dient die Etablierung sog. medizinischer Einsatzteams (engl. medical emergency teams). Dieser werden im Sinne eines präventiven Therapieansatzes bei erkennbaren Abweichungen der Vitalparameter frühzeitig alarmiert. Durch diesen präventiven Therapieansatz können innerklinische Kreislaufstillstände und ungeplante Aufnahmen auf eine Intensivstation vermieden und die perioperative Patientensicherheit erhöht werden.

Background The authors hypothesized that low tidal volume (VT) would minimize ventilator-induced lung injury regardless of the degree of mechanical power. The authors investigated the impact of power, obtained by different combinations of VT and respiratory rate (RR), on ventilator-induced lung injury in experimental mild acute respiratory distress syndrome (ARDS). Methods Forty Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 h, 32 rats were randomly assigned to be mechanically ventilated (2 h) with a combination of different VT (6 ml/kg and 11 ml/kg) and RR that resulted in low and high power. Power was calculated as energy (ΔP,L2/E,L) × RR (ΔP,L = transpulmonary driving pressure; E,L = lung elastance), and was threefold higher in high than in low power groups. Eight rats were not mechanically ventilated and used for molecular biology analysis. Results Diffuse alveolar damage score, which represents the severity of edema, atelectasis, and overdistension, was increased in high VT compared to low VT, in both low (low VT: 11 [9 to 14], high VT: 18 [15 to 20]) and high (low VT: 19 [16 to 25], high VT: 29 [27 to 30]) power groups. At high VT, interleukin-6 and amphiregulin expressions were higher in high-power than in low-power groups. At high power, amphiregulin and club cell protein 16 expressions were higher in high VT than in low VT. Mechanical energy and power correlated well with diffuse alveolar damage score and interleukin-6, amphiregulin, and club cell protein 16 expression. Conclusions In experimental mild ARDS, even at low VT, high mechanical power promoted ventilator-induced lung injury. To minimize ventilator-induced lung injury, low VT should be combined with low power.

BackgroundSystemic toxicity of local anesthetics is predominantly complicated by their myocardial toxicity. Especially long-acting local anesthetics exert a negative inotropic effect that has been described at lower concentrations than defined for blockade of myocardial ion channels. We evaluated the negative inotropic effect of bupivacaine at a concentration described for clinical toxicity testing the hypothesis that negative inotropy is a result of reduced Ca2+ sensitivity rather than blockade of ion channels.MethodsWe simultaneously measured force development and action potentials in guinea pig right papillary muscles (n = 5 to 7). L-type Ca2+ currents (n = 8 to 16) and Ca2+ transients (n = 10 to 11) were measured in isolated cardiomyocytes. Sensitivity of myofilaments to Ca2+ was assessed in skinned fibers (n = 10). Potential effects of bupivacaine on 3′,5′-cyclic adenosine monophosphate concentrations were measured using Förster Resonance Energy Transfer (n = 12 to 14) microscopy.ResultsBupivacaine reduced force in a concentration-dependent manner from 173 ± 119 µN at baseline to 28 ± 13 µN at 300 µM (mean ± SD). At concentrations giving half-maximum negative inotropic effects (5 µM), the maximum upstroke velocity of action potentials, as a surrogate of sodium channel activity, was unaffected. Maximum positive inotropic effects of isoprenaline were also reduced to 50%. Neither basal nor isoprenaline-induced 3′,5′-cyclic adenosine monophosphate accumulation, L-type Ca2+ currents, or Ca2+ transients were affected by 5 µM bupivacaine, but this concentration significantly decreased Ca2+ sensitivity of myofilaments, changing the negative logarithm of the half-maximum effective Ca2+ concentrations from 5.66 to 5.56 –log[M].ConclusionsWe provide evidence that the negative inotropic effect of bupivacaine may be caused mainly by a reduction in myofilament sensitivity to Ca2+.

BackgroundProlonged catheter use is controversial because of the risk of catheter-related infection, but the extent to which the risk increases over time remains unknown. We thus assessed the time-dependence of catheter-related infection risk up to 15 days.MethodsOur analysis was based on the German Network for Regional Anesthesia, which includes 25 centers. We considered 44,555 patients who had surgery between 2007 and 2014 and had continuous regional anesthesia as well as complete covariable details. Cox regression analysis was performed and adjusted for confounding covariables to examine the relationship between catheter duration and probability of infection-free catheter use.ResultsAfter adjustment for confounding factors, the probability of infection-free catheter use decreases with each day of peripheral and epidural catheter use. In peripheral catheters, it was 99% at day 4 of catheter duration, 96% at day 7, and 73% at day 15. In epidural catheters, it was 99% at day 4 of catheter duration, 95% at day 7, and 73% at day 15. Only 31 patients (0.07%) had severe infections that prompted surgical intervention. Among these were five catheters that initially had only mild or moderate signs of infection and were left in situ; all progressed to severe infections.ConclusionsInfection risk in catheter use increases over time, especially after four days. Infected catheters should be removed as soon as practical.

Background/objective Headache in pupils is underestimated and has a negative impact on learning and life. The aim of this study was to investigate headache prevalence and its collateral effects, in pupils of different ages and school types in a German city. Methods Anonymized questionnaires were distributed to 5419 pupils attending primary and secondary schools. Demographics, headache frequency, analgesic use, school absence and, for secondary school children, data on lifestyle were collected. Results The questionnaire was returned by 2706 children (49%), 1362 (50.3%) girls, 1344 (49.7%) boys. Of these, 36.6% indicated a frequency of 1, and 31.5% a frequency of ≥ 2 headache days per month within the last 3 months. Headache prevalence increased with school grade, age and secondary school type: 63.6%, 67.2% and 79.5% for primary school children, pupils attending 8-year and pupils attending 6-year secondary schools, respectively. With secondary school level I certificates, pupils are prepared for general professional training in 6 years. Secondary school level II results, after 8 years of training, in university entrance level II certificates, which are the precondition for university studies. Girls reported significantly more headache than boys (73% vs. 63.1%). A significant relationship has been observed between headache frequency and school absence and between headache intensity and headache frequency. Of pupils with headache at least twice a month, 48.1% reported analgesic intake. Ibuprofen (49.1%) and paracetamol (32.8%) were the most frequently used analgesics. Of those pupils with headache ≥ 2 days/month, 68.3% did not have a specific headache diagnosis. Concomitant diseases and regular drug intake, analgesic intake for another reason than headache, caffeine consumption and lack of participation in sports were positively correlated with headache. Conclusions The majority of pupils suffer from headache at least once a month. Since frequent headache results in educational and social limitations, pupils at risk should be identified and referred to headache education programs. Efforts are needed to improve the management of juvenile headache patients.

Rationale We investigated the effects of vaporized perfluorohexane (PFH) on pulmonary vascular tone, pulmonary vascular resistance and peak inspiratory pressure as well as lipid mediator formation in the treatment of calcium ionophore induced lung injury in a model of the isolated perfused and ventilated rabbit lungs. Methods Lung injury was induced in isolated perfused and ventilated rabbit lungs by calcium ionophore A23187. Lungs were treated with either 4.5 vol.% (4.5 vol.% PFH; n = 6) or 18 vol.% (18 vol.% PFH; n = 6) PFH. Six lungs remained untreated (Control). In addition 5 lungs (PFH-sham) remained uninjured receiving 18 vol.% PFH only. Mean pulmonary artery pressure (mPAP), peak inspiratory pressure ( P max ), and lung weight (weight) were monitored for 120 min. Experiments were terminated before when the increase in lung weight exceeded 40 g. Perfusate samples were taken at regular intervals for analysis of TXB 2 , 6-keto-PGF 1 and LTB 4 . Results Controls reached the study end point significantly earlier than both PFH groups. Significant differences were found for a weight gain of 10 g and 20 g between the control and the 4.5 vol.% PFH and the 18 vol.% PFH. Differences in mPAP were more pronounced in the 4.5 vol.% PFH. However increases in P max were more marked in 4.5 vol.% PFH. TXA 2 -, PGI 2 -, and LTB 4 -levels were significantly lower in PFH groups. Uninjured lungs remained unaffected by the presence of 18 vol.% PFH. Conclusion Inflammatory lung injury was attenuated by the treatment with 4.5 vol.% PFH and 18 vol.% PFH vapor in the isolated perfused rabbit lung. Therapeutic effects were more pronounced with a concentration of 4.5 vol.% PFH.

BackgroundCatheter-related infection is a serious complication of continuous regional anesthesia. The authors tested the hypothesis that single-dose antibiotic prophylaxis is associated with a lower incidence of catheter-related infections.MethodsOur analysis was based on cases in the 25-center German Network for Regional Anesthesia database recorded between 2007 and 2014. Forty thousand three hundred sixty-two surgical patients who had continuous regional anesthesia were grouped into no antibiotic prophylaxis (n = 15,965) and single-dose antibiotic prophylaxis (n = 24,397). Catheter-related infections in each group were compared with chi-square test after 1:1 propensity-score matching. Odds ratios (ORs [95% CI]) were calculated with logistic regression and adjusted for imbalanced variables (standardized difference more than 0.1).ResultsPropensity matching successfully paired 11,307 patients with single-dose antibiotic prophylaxis (46% of 24,397 patients) and with 11,307 controls (71% of 15,965 patients). For peripheral catheters, the incidence without antibiotics (2.4%) was greater than with antibiotic prophylaxis (1.1%, P < 0.001; adjusted OR, 2.02; 95% CI, 1.49 to 2.75, P < 0.001). Infections of epidural catheters were also more common without antibiotics (5.2%) than with antibiotics (3.1%, P < 0.001; adjusted OR, 1.94; 95% CI, 1.55 to 2.43, P < 0.001).ConclusionsSingle-dose antibiotic prophylaxis was associated with fewer peripheral and epidural catheter infections.

Catheter-related infections are a serious complication of continuous thoracic epidural analgesia. Tunnelling catheters subcutaneously may reduce infection risk. We thus tested the hypothesis that tunnelling of thoracic epidural catheters is associated with a lower risk of catheter-related infections.Twenty-two thousand, four hundred and eleven surgical patients with continuous thoracic epidural analgesia included in the German Network for Regional Anaesthesia registry between 2007 and 2014 were grouped by whether their catheters were tunnelled (n=12 870) or not (n=9541). Catheter-related infections in each group were compared with Student's unpaired t and χ(2) tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic regression, adjusting for potential confounding factors, including age, ASA physical status score, use of catheter for ≥4 days, multiple skin puncture, hospital, and surgical department.There were fewer catheter-related infections in patients with tunnelled catheters (4.5 vs 5.5%, P0.001). Mild infections were also less common (4.0 vs 4.6%, P=0.009), as were moderate infections (0.4 vs 0.8%, P0.001). After adjustment for potential confounding factors, tunnelling remained an independent prevention for any grade of infection (adjusted OR 0.51, 95% CI 0.42-0.61, P0.001) and for mild infections (adjusted OR 0.54, 95% CI 0.43-0.66, P0.001) and moderate and severe infections (adjusted OR 0.44, 95% CI 0.28-0.70, P=0.001).Tunnelling was associated with a lower risk of thoracic epidural catheter-related infections.

Background Ischemic stroke causes brain inflammation, which we postulate may result in lung damage. Several studies have focused on stroke-induced immunosuppression and lung infection; however, the possibility that strokes may trigger lung inflammation has been overlooked. We hypothesized that even focal ischemic stroke might induce acute systemic and pulmonary inflammation, thus altering respiratory parameters, lung tissue integrity, and alveolar macrophage behavior. Methods Forty-eight Wistar rats were randomly assigned to ischemic stroke (Stroke) or sham surgery (Sham). Lung function, histology, and inflammation in the lung, brain, bronchoalveolar lavage fluid (BALF), and circulating plasma were evaluated at 24 h. In vitro, alveolar macrophages from naïve rats (unstimulated) were exposed to serum or BALF from Sham or Stroke animals to elucidate possible mechanisms underlying alterations in alveolar macrophage phagocytic capability. Alveolar macrophages and epithelial and endothelial cells of Sham and Stroke animals were also isolated for evaluation of mRNA expression of interleukin (IL)-6 and tumor necrosis factor (TNF)-α. Results Twenty-four hours following ischemic stroke, the tidal volume, expiratory time, and mean inspiratory flow were increased. Compared to Sham animals, the respiratory rate and duty cycle during spontaneous breathing were reduced, but this did not affect lung mechanics during mechanical ventilation. Lungs from Stroke animals showed clear evidence of increased diffuse alveolar damage, pulmonary edema, and inflammation markers. This was associated with an increase in ultrastructural damage, as evidenced by injury to type 2 pneumocytes and endothelial cells, cellular infiltration, and enlarged basement membrane thickness. Protein levels of proinflammatory mediators were documented in the lung, brain, and plasma (TNF-α and IL-6) and in BALF (TNF-α). The phagocytic ability of macrophages was significantly reduced. Unstimulated macrophages isolated from naïve rats only upregulated expression of TNF-α and IL-6 following exposure to serum from Stroke rats. Exposure to BALF from Stroke or Sham animals did not change alveolar macrophage behavior, or gene expression of TNF-α and IL-6. IL-6 expression was increased in macrophages and endothelial cells from Stroke animals. Conclusions In rats, focal ischemic stroke is associated with brain–lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which seems to be promoted by systemic inflammation. Electronic supplementary material The online version of this article (10.1186/s13054-018-2164-0) contains supplementary material, which is available to authorized users.

INTRODUCTION Gastric aspiration events are recognized as a major cause of pneumonitis and the development of acute respiratory distress syndrome. The first peak in the inflammatory response has been observed one hour after acid-induced lung injury in rats. The spatial pulmonary blood flow (PBF) distribution after an acid aspiration event within this time frame has not been adequately studied. We determined therefore PBF pattern within the first hour after acid aspiration. METHODS Anesthetized, spontaneous breathing rats (n = 8) underwent unilateral endobronchial hydrochlorid acid instillation so that the PBF distributions between the injured and non-injured lungs could be compared. The signal intensity of the lung parenchyma after injury was measured by magnetic resonance tomography. PBF distribution was determined by measuring the concentration of [68Ga]-radiolabeled microspheres using positron emission tomography. RESULTS Following acid aspiration, magnetic resonance images revealed increased signal intensity in the injured regions accompanied by reduced oxygenation. PBF was increased in all injured lungs (171 [150; 196], median [25%; 75%]) compared to the blood flow in all uninjured lungs (141 [122; 159], P = 0.0078). CONCLUSIONS From the first minute until fifty minutes after acid-induced acute lung injury, the PBF was consistently increased in the injured lung. These blood flow elevation was accompanied by significant hypoxemia.

Background Obesity is believed to increase the risk of surgical site infections and possibly increase the risk of catheter-related infections in regional anesthesia. We, therefore, analyzed the influence of obesity on catheter-related infections defined within a national registry for regional anesthesia. Methods The German Network for Regional Anesthesia database with 25 participating clinical centers was analyzed between 2007 and 2012. Exactly, 28,249 cases (13,239 peripheral nerve and 15,010 neuraxial blocks) of patients ≥ 14 years were grouped in I: underweight (BMI 13.2–18.49 kg/m2, n = 597), II: normal weight (BMI 18.5–24.9 kg/m2, n = 9272), III: overweight (BMI 25.0–29.9 kg/m2, n = 10,632), and IV: obese (BMI 30.0–70.3 kg/m2, n = 7,744). The analysis focused on peripheral and neuraxial catheter-related infections. Differences between the groups were tested with non-parametric ANOVA and chi-square (P

Psoas blocks are an alternative to femoral nerve blocks and have the potential advantage of blocking the entire lumbar plexus. However, the psoas muscle is located deeply, making psoas blocks more difficult than femoral blocks. In contrast, while femoral blocks are generally easy to perform, the inguinal region is prone to infection. We thus tested the hypothesis that psoas blocks are associated with more insertion-related complications than femoral blocks but have fewer catheter-related infections.We extracted 22,434 surgical cases from the German Network for Regional Anesthesia registry (2007-2014) and grouped cases as psoas (n = 7593) and femoral (n = 14,841) blocks. Insertion-related complications (including single-shot blocks and catheter) and infectious complications (including only catheter) in each group were compared with χ tests. The groups were compared with multivariable logistic models, adjusted for potential confounding factors.After adjustment for potential confounding factors, psoas blocks were associated with more complications than femoral blocks including vascular puncture 6.3% versus 1.1%, with an adjusted odds ratio (aOR) of 3.6 (95% confidence interval [CI], 2.9-4.6; P0.001), and multiple skin punctures 12.6% versus 7.7%, with an aOR of 2.6 (95% CI, 2.1-3.3; P0.001). Psoas blocks were also associated with fewer catheter-related infections: 0.3% versus 0.9% (aOR of 0.4; 95% CI, 0.2-0.8; P = 0.016), and with improved patient satisfaction (mean ± SD 0- to 10-point scale score, 9.6 ± 1.2 vs 8.4 ± 2.9; P0.001). Results from a propensity-matched sensitivity analysis were similar.Psoas blocks are associated with more insertion-related complications but fewer infectious complications.ID NCT02846610.

Aim of the study Many hospitals have basic life support (BLS) training programmes, but the effects on the quality of chest compressions are unclear. This study aimed to evaluate the no-flow fraction (NFF) during BLS provided by standard care nursing teams over a five-year observation period during which annual participation in the BLS training was mandatory. Methods All healthcare professionals working at Dresden University Hospital were instructed in BLS and automated external defibrillator (AED) use according to the current European Resuscitation Council guidelines on an annual basis. After each cardiac arrest occurring on a standard care ward, AED data were analyzed. The time without chest compressions during the period without spontaneous circulation (i.e., the no-flow fraction) was calculated using thoracic impedance data. Results For each year of the study period (2008–2012), a total of 1454, 1466, 1487, 1432, and 1388 health care professionals, respectively, participated in the training. The median no-flow fraction decreased significantly from 0.55 [0.42; 0.57] (median [25‰; 75‰]) in 2008 to 0.3 [0.28; 0.35] in 2012. Following revision of the BLS curriculum after publication of the 2010 guidelines, cardiac arrest was associated with a higher proportion of patients achieving ROSC (72% vs. 48%, P =0.025) but not a higher survival rate to hospital discharge (35% vs. 19%, P =0.073). Conclusion The NFF during in-hospital cardiac resuscitation decreased after establishment of a mandatory annual BLS training for healthcare professionals. Following publication of the 2010 guidelines, more patients achieved ROSC after in-hospital cardiac arrest.

Spontaneous Breathing during General Anesthesia Prevents the Ventral Redistribution of Ventilation as Detected by Electrical Impedance Tomography A Randomized Trial Oliver C. Radke, M.D., Ph.D., D.E.A.A.,* Thomas Schneider,† Axel R. Heller, M.D., Ph.D.,‡ Thea Koch, M.D., Ph.D.§ ABSTRACT What We Already Know about This Topic • Controlled mechanical ventilation under general anesthesia increases ventilation in the ventral parts of the lung • We do not know whether pressure support ventilation prevents the redistribution of ventilation Background: Positive-pressure ventilation causes a ventral redistribution of ventilation. Spontaneous breathing during general anesthesia with a laryngeal mask airway could pre- vent this redistribution of ventilation. We hypothesize that, compared with pressure-controlled ventilation, spontaneous breathing and pressure support ventilation reduce the extent of the redistribution of ventilation as detected by electrical impedance tomography. Methods: The study was a randomized, three-armed, obser- vational, clinical trial without blinding. With approval from the local ethics committee, we enrolled 30 nonobese patients without severe cardiac or pulmonary comorbidities who were scheduled for elective orthopedic surgery. All of the proce- dures were performed under general anesthesia with a laryn- geal mask airway and a standardized anesthetic regimen. The center of ventilation (primary outcome) was calculated be- fore the induction of anesthesia (AWAKE), after the place- ment of the laryngeal mask airway (BEGIN), before the end What This Article Tells Us That Is New • Using a noninvasive and radiation-free imaging technique of lung function, electric impedance tomography, under general anesthesia in nonparalyzed adults, this study demonstrates no difference of regional ventilation distribution between the modes of pressure-controlled ventilation and pressure sup- port ventilation, whereas spontaneous breathing prevented the redistribution of anesthesia (END), and after arrival in the postanesthesia care unit (PACU). Results: The center of ventilation during anesthesia (BEGIN) was higher than baseline (AWAKE) in both the pressure-controlled and pressure support ventilation groups (pressure control: 55.0 vs. 48.3, pressure support: 54.7 vs. 48.8, respectively; multivariate analysis of covariance, P ⬍ 0.01), whereas the values in the spontaneous breathing group remained at baseline levels (47.9 vs. 48.5). In the post- anesthesia care unit, the center of ventilation had returned to the baseline values in all groups. No adverse events were recorded. Conclusions: Both pressure-controlled ventilation and pres- sure support ventilation induce a redistribution of ventila- tion toward the ventral region, as detected by electrical im- pedance tomography. Spontaneous breathing prevents this redistribution. * Assistant Clinical Professor, San Francisco General Hospital, Department of Anesthesia & Perioperative Care, University of Cali- fornia San Francisco, San Francisco, California, and Senior Attending Anesthesiologist, Klinik und Poliklinik fu¨r Anasthesiologie und In- tensivtherapie, Fetscherstr, Dresden, Germany. † Ph.D. Student, ‡ Professor of Anesthesia, § Chair, Klinik und Poliklinik fu¨r Ana¨s- thesiologie und Intensivtherapie, Fetscherstr. Received from Klinik und Poliklinik fu¨r Ana¨sthesiologie und Intensivtherapie, Fetscherstr, Dresden, Germany. Submitted for publication March 22, 2011. Accepted for publication February 6, 2012. Support was provided solely from institutional and/or depart- mental sources. Dra¨ger Medical (Lu¨beck, Germany) provided the electrical impedance tomography prototype free of charge for use in this study. Presented as a poster at the annual meeting of the American Thoracic Society, May 15, 2011, Denver, Colorado, and at the meeting of the European Association of Cardiothoracic Anaes- thesiologists, June 3, 2011, Vienna, Austria. Address correspondence to Dr. Radke: San Francisco General Hospital, Department of Anesthesia & Perioperative Care, University of California San Francisco, 1001 Potrero Avenue, San Francisco, California 94110. oradke@pcat.de. Information on purchasing re- prints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. A NESTHESIOLOGY ’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue. I NTUBATION and mechanical ventilation cause a redis- tribution of ventilation: 1,2 compared with spontaneous breathing (SB) in the awake state in supine position, positive- 䉬 This article is accompanied by an Editorial View. Please see: Canet J, Gallart L: The dark side of the lung: Unveiling regional lung ventilation with electrical impedance tomog- raphy. A NESTHESIOLOGY 2012; 116:XXX–XXX. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2012; 116:1–1 Anesthesiology, V 116 • No 6 June 2012

Zur operativen Versorgung einer Schnittverletzung der Hand erhielt eine 22-jahrige Patientin eine axillare Plexusanasthesie. Postoperativ trat eine Methamoglobinamie auf, die mit Toluidinblau behandelt wurde. In der Folge kam es zu einem Kammerflimmern. Diskutiert werden die derzeitigen Behandlungsalternativen der Methamoglobinamie.

The intraperitoneal instillation of perfluorocarbons augmented systemic oxygenation and was protective in mesenteric ischemia-reperfusion and experimental lung injury. To study biocompatibility and potential anti-inflammatory effects of intraperitoneal perfluorocarbons, we evaluated the influence of perfluorohexane and/or inflammatory stimuli on human mesothelial cells in vitro. Perfluorohexane exposure neither impaired cell viability nor induced cellular activation. TNFα enhanced ICAM-1 expression, which was not attenuated by simultaneous perfluorohexane treatment. Concentration of intracellular surfactant protein A tended to be higher in perfluorohexane treated cells compared to controls. Our in vitro data add further evidence that intraperitoneal perfluorocarbon application is feasible without adverse local effects.

Summary A 5-week-old preterm infant was scheduled for inguinal hernia repair. Following induction of general anaesthesia, 10 mg.kg−1 ropivacaine was injected, accidently, into the caudal space. The infant developed cardiac depression with bradycardia (minimum heart rate 50 beats.min−1), elevated T waves and widening of QRS complexes. Resuscitation by means of external chest compression, intravenous adrenaline and fluid administration was successful. Ropivacaine serum concentrations were obtained at three time points yielding a peak level of 6 μg.ml−1 20 min after caudal injection.

There is growing interest in the use of both variable and pressure-controlled ventilation (PCV). The combination of these approaches as “noisy PCV” requires adaptation of the mechanical ventilator to the respiratory system mechanics. Thus, we developed and evaluated a new control system based on the least-mean-squares adaptive approach, which automatically and continuously adjusts the driving pressure during PCV to achieve the desired variability pattern of tidal volume (V T). The controller was tested during numerical simulations and with a physical model reproducing the mechanical properties of the respiratory system. We applied step changes in respiratory system mechanics and mechanical ventilation settings. The time needed to converge to the desired V T variability pattern after each change (t c) and the difference in minute ventilation between the measured and target pattern of V T (ΔMV) were determined. During numerical simulations, the control system for noisy PCV achieved the desired variable V T pattern in less than 30 respiratory cycles, with limited influence of the dynamic elastance (E*) on t c, except when E* was underestimated by >25%. We also found that, during tests in the physical model, the control system converged in

In der Klinik fur Anasthesiologie und Intensivtherapie der Universitatsklinik Dresden wurde das im Jahr 2003 etablierte anonyme Erfassungssystem kritischer Ereignisse auf eine intranetbasierte Form umgestellt und auf die Intensivstation ausgeweitet. In den ersten 18 Monaten wurden 70 Meldungen von der Intensivstation registriert. Die meisten Meldungen bezogen sich auf das Infusionsmanagement, gefolgt von Atemwegsmanagement, Herz-Kreislauf-Management, neurologischen Problemen und Fehlern in der Medikamentenapplikation. Als haufigste Ursachen wurden mangelnde Aufmerksamkeit, fehlende Uberprufung von Masnahmen, Arbeitsbelastung des Pflegepersonals, unzureichende Erfahrung und Kommunikationsdefizite genannt. In diesem Beitrag werden die Haufigkeiten von Fehlern auf Intensivstationen und deren potenzielle Auswirkungen diskutiert.

Uber die Haufigkeit von Fehlern in der Anasthesie und Intensivmedizin gibt es wenig exakte Zahlen, man muss aber davon ausgehen, dass Fehler viel haufiger auftreten als wir es alle erwarten. Die Komplexitat unserer Arbeitswelt hat hierbei einen nicht unerheblichen Anteil. Die Gefahren, die sich aus Fehlern ableiten, sind Storungen des Genesungsprozesses der Patienten bis hin zur Beeintrachtigung der korperlichen Unversehrtheit, rechtliche und finanzielle Folgen fur die beteiligten Personen und die Trager sowie eine Beeintrachtigung der Mitarbeiterzufriedenheit und -belastbarkeit. Der Beitrag beschreibt verschiedene Methoden, Fehler in einem Prozessablauf zu identifizieren, und unterstreicht den Wert einer Analyse der erkannten Fehler zur Fehlerreduktion. Die Ergebnisse der Analysen sollten veroffentlicht werden, wenn sie von allgemeinem Interesse sind.

Zusammenfassung Chronische Schmerzen bedingen angesichts ihrer bio-psycho-sozialen Komplexitat und der facherubergreifenden Prasenz eine interdisziplinare Zusammenarbeit. Diese erst ermoglicht eine umfassende Einordnung des Befundes und ist Vorraussetzung fur ein individuelles und ressourcenorientiertes Therapiekonzept mit dem Schwerpunkt der korperlichen und psychischen Aktivierung. Dieses Konzept ist Behandlungsschwerpunkt des UniversitatsSchmerzCentrums (USC), das im April 2004 im Universitatsklinikum Dresden gegrundet wurde und seitdem neben der bereits etablierten ambulanten Therapie auch teilstationare und stationare Versorgung ermoglicht. Ausgangspunkt der Grundungsinitiative fur das Schmerzzentrum war die Sensibilisierung der Kostentrager fur die komplexe Proble-matik des chronischen Schmerzes und ebenso fur die bestehenden regionalen Strukturdefizite. Gefolgt von der Vorlage eines schlussigen multimodalen, fachubergreifenden Behandlungskonzeptes mit ausfuhrlicher Kostenkalkulation wurde nach 1 1 2 -jahriger Arbeitsphase im Juni 2004 ein Vertrag zur integrierten Versorgung mit der AOK Sachsen und dem VdAK unterzeichnet. Nach nun zweijahriger Behandlungsphase sollen erste Erfahrungen und Ergebnisse, insbesondere der tagesklinischen Therapiesaule des Schmerzzentrums innerhalb des IV-Vertrages, dargestellt werden.

Background: Aspiration-induced lung injury can decrease gas exchange and increase mortality. Acute lung injury following acid aspiration is characterized by elevated pulmonary blood flow (PBF) in damaged lung areas in the early inflammation stage. Knowledge of PBF patterns after acid aspiration is important for targeting intravenous treatments. We examined PBF in an experimental model at a later stage (2 hours after injury). Methods: Anesthetized Wistar-Unilever rats (n = 5) underwent unilateral endobronchial instillation of hydrochloric acid. The PBF distribution was compared between injured and uninjured sides and with that of untreated control animals (n = 6). Changes in lung density after injury were measured using computed tomography (CT). Regional PBF distribution was determined quantitatively in vivo 2 hours after acid instillation by measuring the concentration of [ 68 Ga]-radiolabeled microspheres using positron emission tomography. Results: CT scans revealed increased lung density in areas of acid aspiration. Lung injury was accompanied by impaired gas exchange. Acid aspiration decreased the arterial pressure of oxygen from 157 mmHg [139;165] to 74 mmHg [67;86] at 20 minutes and tended toward restoration to 109 mmHg [69;114] at 110 minutes (P < 0.001). The PBF ratio of the middle region of the injured versus uninjured lungs of the aspiration group (0.86 [0.7;0.9], median [25%;75%]) was significantly lower than the PBF ratio in the left versus right lung of the control group (1.02 [1.0;1.05]; P = 0.016). Conclusions: The PBF pattern 2 hours after aspiration-induced lung injury showed a redistribution of PBF away from injured regions that was likely responsible for the partial recovery from hypoxemia over time. Treatments given intravenously 2 hours after acid-induced lung injury may not preferentially reach the injured lung regions, contrary to what occurs during the first hour of inflammation.

Supplementation of clinical nutrition with omega-3 fatty acid in fish oil exerts immune-modulating and organ-protective effects, even after short-term application. The aim of this study was to evaluate dose-dependent effects of parenteral supplementation of a 10% fish oil emulsion (Omegaven, Fresenius-Kabi, Bad Homburg, Germany) on diagnosis- and organ failure-related outcome.Prospective, open label, multiple-center trial.A total of 661 patients from 82 German hospitals receiving total parenteral nutrition foror =3 days were enrolled in this study. The sample included 255 patients after major abdominal surgery, 276 with peritonitis and abdominal sepsis, 16 with nonabdominal sepsis, 59 after multiple trauma, 18 with severe head injury, and 37 with other diagnoses. The primary study end point was survival; secondary end points were length of hospital stay and use of antibiotics with respect to the primary diagnosis and the extent of organ failure. Multiple quasi-linear and logistic regression models were used for calculating diagnosis-related fish oil doses associated with best outcome.The patients enrolled in this survey were (mean +/- sd) 62.8 +/- 16.5 yrs old, with a body mass index of 25.1 +/- 4.2 and Simplified Acute Physiology Score (SAPS) II score of 32.2 +/- 13.6. Length of hospital stay was 29.1 +/- 18.7 days (12.5 +/- 14.8 days in the intensive care unit). Total parenteral nutrition, including fish oil (mean, 0.11 g.kg(-1).day(-1)), was administered for 8.7 +/- 7.5 days and lowered hospital mortality as predicted by Simplified Acute Physiology Score II from 18.9% (95% confidence interval, 17.4-20.4%) to 12.0% (p.001). The fish oil dose.kg.day did correlate with beneficial outcome (intensive care unit stay, hospital stay, mortality). Fish oil had the most favorable effects on survival, infection rates, and length of stay when administered in doses between 0.1 and 0.2 g.kg(-1).day(-1). Lower antibiotic demand by 26% was observed when doses of 0.15-0.2 g.kg(-1).day(-1) were infused as compared with doses of0.05 g.kg(-1).day(-1). After peritonitis and abdominal sepsis, multiple quasi-linear regression models revealed a fish oil dose for minimizing intensive care unit stay of 0.23 g.kg(-1).day(-1) and an inverse linear relationship between dosage and intensive care unit stay in major abdominal surgery.Administration of omega-3 fatty acid may reduce mortality, antibiotic use, and length of hospital stay in different diseases. Effects and effect sizes related to fish oil doses are diagnosis dependent. In view of the lack of substantial study literature concerning diagnosis-related nutritional single-substrate intervention in the critically ill, the present data can be used in formulating hypotheses and may serve as reference doses for randomized, controlled studies, which may, for instance, confirm the value of omega-3 fatty acid in the adjunctive therapy of peritonitis and abdominal sepsis.

In der Klinik fur Anasthesiologie und Intensivtherapie der Universitatsklinik Dresden wurde vor 2 Jahren ein anonymes Meldesystem kritischer Ereignisse etabliert. Innerhalb der ersten 18 Monate gingen insgesamt 162 Meldungen ein. Diese Meldungen wurden systematisch analysiert. Die meisten Meldungen bezogen sich auf das Beatmungs-/Atemwegsmanagement, gefolgt vom Infusionsmanagement und dem Herz-/Kreislaufmanagement. Als haufigste Ursachen wurden mangelnde Aufmerksamkeit, mangelnde Erfahrung, spezielle Ausbildungsdefizite und Kommunikationsschwachen angegeben. Das Vertrauen in die Anonymitat des Systems war sehr hoch. Als Folge der Meldungen wurden zahlreiche Veranderungen initiiert. Diese bestanden beispielsweise aus gezielten Ausbildungsmasnahmen und der Definition von Standards. Bereits nach einem kurzen Zeitraum wurden Veranderungen in relativen Fehlerverteilungen registriert. In dem Artikel werden die verschiedenen Fehlerarten diskutiert sowie die Aspekte erortert, die insbesondere nach der Initialphase eines lokalen Erfassungssystems beachtet werden sollten, um die Meldebereitschaft auf hohem Niveau zu stabilisieren.

Epidemiologic studies have indicated that high intake of saturated fat and/or animal fat increases the risk of colon and breast cancer. Omega-3 PUFAs in fish oil (FO) can inhibit the growth of human cancer cells in vitro and in vivo. These effects are related to the uptake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) into the cellular substrate pool and their competitive metabolism with arachidonic acid (AA) at the cyclooxygenase and 5-lipoxygenase levels. The metabolites of EPA and DHA have less inflammatory and immunosuppressant potency than the substances derived from AA. Based on previous experimental data, we hypothesized that FO supplementation after major abdominal cancer surgery would improve hepatic and pancreatic function. Ours was a prospective, randomized, double-blinded clinical trial on 44 patients undergoing elective major abdominal surgery, randomly assigned to receive total parenteral nutrition (TPN) supplemented with either soybean oil (SO 1.0 g/kg body weight daily, n = 20) for 5 days or a combination of FO and SO (FO 0.2 + SO 0.8 g/kg body weight daily, n = 24). Compared to pure SO supplementation in the postoperative period, FO significantly reduced ASAT [0.8 +/- 0.1 vs. 0.5 +/- 0.1 mmol/(l. sec)], ALAT [0.9 +/- 0.1 vs. 0.6 +/- 0.1 mmol/(l. sec)], bilirubin (16.1 +/- 5.3 vs. 6.9 +/- 0.6 mmol/l), LDH (7.7 +/- 0.4 vs. 6.7 +/- 0.4 mmol/(l. sec) and lipase (0.6 +/- 0.1 vs. 0.4 +/- 0.1 micromol/(l. sec) in the postoperative course. Moreover, patients with increased risk of sepsis (IL-6/IL-10 ratio >8) showed a tendency to shorter ICU stay (18 hr) under omega-3 PUFA treatment. Weight loss as encountered after the SO emulsion of 1.1 +/- 2.2 kg was absent in the FO group. After major abdominal tumor surgery, FO supplementation improved liver and pancreas function, which might have contributed to the faster recovery of patients.

Fragestellung Die Inhalation von Perfluorhexan (PFH) fuhrt im Olsaure-induzierten Lungenversagen am Schaf zu einer Verbesserung der Oxygenierung und der mechanischen Lungenfunktion. Ziel der Untersuchung war es, Effekte von PFH bei der Therapie eines experimentellen „acute respiratory distress syndrome“ (ARDS) uber einen langeren Beobachtungszeitraum (4 h) zu untersuchen sowie die Moglichkeit einer schrittweisen Reduktion der inspiratorischen Sauerstofffraktion (FIO2) in der Behandlungsgruppe zu evaluieren.

Im Rahmen von Spinalanasthesien (SPA) kann die Ausbreitung der sensorischen und sympathischen Blockade durch Lagewechsel sowohl nach der Anwendung von isobaren wie auch hyperbaren Lokalanasthetika (LA) unvorhersehbar zunehmen. Wir berichten in diesem Zusammenhang uber einen 50-jahrigen adiposen Patienten, bei dem zur Versorgung einer Unterschenkelfraktur eine SPA mit 17,5 mg 0,5%igem isobarem Bupivacain durchgefuhrt wurde. Nach 15 min erreichte die Ausbreitung der sensorischen Blockade ihr Maximum bei Th8. Nach 15° Oberkorperhochlagerung, 35 min nach der intrathekalen Injektion des LA, kam es innerhalb der nachsten 10 min zu einer unbeabsichtigten Zunahme der kranialen Ausbreitung um 10 Segmente bis C6. Der Patient wurde bradykard, hypoton, respiratorisch insuffizient und musste intubiert und beatmet werden. Die Hamodynamik wurde durch die intravenose Applikation von Akrinor®, Atropin und kolloidalen Volumenersatzmitteln rasch stabilisiert. Die anschliesende Operation erfolgte ohne Besonderheiten in Intubationsnarkose. Bei Operationsende wurde der Patient bei stabiler Hamodynamik und suffizienter Spontanatmung problemlos extubiert. Unmittelbar nach Extubation erreichte die kraniale sensorische Ausbreitung L2. Die Kasuistik zeigt, dass es auch nach vermeintlicher Fixierung des LA zu einer unerwarteten Zunahme der Blockade nach Lagewechsel kommen kann, und dass Patienten nach SPA bis zur Remission der Blockade sorgfaltig uberwacht werden mussen. Die der unbeabsichtigten kranialen Ausbreitung von sensorischer und sympathischer Blockade zugrunde liegenden Pathomechanismen werden diskutiert.

In the heart, the endothelin (ET)/endothelin-receptor system is markedly involved in pathophysiological mechanisms underlying various cardiac diseases. Based upon pharmacological studies both ET-receptor subtypes take part in the regulation of coronary vascular tone, however, their detailed cellular distribution in the coronary vascular bed based upon direct mRNA and protein detection is unknown. This issue was addressed in the rat heart by means of non-radioactive in situ hybridization, RT-PCR, and immunohistochemistry. Expression of vascular ET(A)-receptors was detected in arterial smooth muscle and capillary endothelium while ET(B)-receptors were present in arterial, venous, and capillary endothelium, and in arterial and venous smooth muscle cells. This differential distribution of the ET-receptor subtypes supports the concept that ET(A)- as well as ET(B)-receptors mediate arterial vasoconstriction, while postcapillary vascular resistance is exclusively regulated by ET(B)-receptors. The observed capillary endothelial expression of the ET(A)-receptor correlates with the known ability of ET(A)-receptor antagonists to attenuate increases in cardiac microvascular permeability during endotoxin shock and ischemia/reperfusion injury.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory disorder of the peripheral nervous system with progressive or relapsing signs in more than one limb, ending in prolonged periods of disability. There are no guidelines for anesthesia in this uncommon paralyzing disease. This report features a 19-year-old woman with CIDP scheduled for an elective cesarean section who had prolonged recovery of motor function after the administration of spinal anesthesia. Although a partial neural block in both feet persisted for 1 day, we conclude that spinal anesthesia is acceptable for cesarean delivery in CIDP-patients when reasonable precautions have been taken.

In a prospective cohort study, Esteban et al. found that about 35% of all patients in intensive care receive mechanical ventilation (1). It has been estimated that, in the USA, mechanical ventilation is given in about 2.8% of all hospitalizations (i.e., about 790 000 patients per year) (2). The treatment cost of ventilated patients is an estimated $27 billion per year, corresponding to about 12% of the total treatment cost of all hospitalized patients (2). Although mechanical ventilation is often life-saving, in that it lessens the work of respiration and enables adequate pulmonary gas exchange for the oxygenation of the body's tissues, it can also cause lung damage, or worsen it if already present (3). This phenomenon is called ventilation-induced lung damage, and its main mechanisms are: high tidal volumes causing overexpansion of the lungs (volutrauma), high airway pressure (barotrauma), cyclical collapse and reopening of atelectatic alveolar regions (atelectrauma) (4). These three types of physical injury lead to a pulmonary inflammatory reaction called "biotrauma,” which often extends beyond the pulmonary parenchyma. It can take the form of a systemic inflammatory reaction, potentially ending in multiple organ system failure. The main pathophysiological mechanisms of ventilation-induced lung damage are shown in the Figure. A further problem is the development of ventilation-associated pneumonia, most often caused by limited mucociliary clearance of the respiratory tract; this is a central challenge in intensive care medicine today. Craven et al. recently reported that about 15% of all ventilated patients develop ventilation-associated pneumonia (5). Modern modes of mechanical ventilation are, therefore, intended to lessen the invasiveness and duration of ventilation to the greatest possible extent in order to prevent such complications. A protective ventilation strategy is important even for patients who do not suffer from any underlying lung disease, as such patients are also exposed to the risk of ventilation-induced lung damage. A meta-analysis by Serpa Neto et al. (6) revealed that, in ventilated patients without any underlying lung disease, the use of a lung-protective mode of ventilation with low tidal volumes significantly lessened not only the frequency of lung damage (relative risk [RR], 0.33; number needed to treat [NNT], 11), but also mortality (RR 0.64, NNT 23). Figure Local and systemic effects of mechanical ventilation – The use of high tidal volumes (volutrauma) and high airway pressures (barotrauma) and the cyclical collapse and reopening of alveolar territories (atelectrauma) can lead to the development ... Although the newer modes of ventilation discussed here have already been the subject of intensive experimental and clinical research, no evidence-based treatment recommendations can be enunciated at present, as no relevant randomized and controlled clinical trials have yet been carried out.

BACKGROUND: Measuring esophageal pressure (Pes) using an air-filled balloon catheter (BC) is the common approach to estimate pleural pressure and related parameters. However, Pes is not routinely measured in mechanically ventilated patients, partly due to technical and practical limitations and difficulties. This study aimed at comparing the conventional BC with two alternative methods for Pes measurement, liquid-filled and air-filled catheters without balloon (LFC and AFC), during mechanical ventilation with and without spontaneous breathing activity. Seven female juvenile pigs (32-42 kg) were anesthetized, orotracheally intubated, and a bundle of an AFC, LFC, and BC was inserted in the esophagus. Controlled and assisted mechanical ventilation were applied with positive end-expiratory pressures of 5 and 15 cmH2O, and driving pressures of 10 and 20 cmH2O, in supine and lateral decubitus. MAIN RESULTS: Cardiogenic noise in BC tracings was much larger (up to 25% of total power of Pes signal) than in AFC and LFC (

Background: Mechanical ventilation can lead to lung biotrauma when mechanical stress exceeds safety thresholds. The authors investigated whether the duration of mechanical stress, that is, the impact of a stress versus time product (STP), influences biotrauma. The authors hypothesized that higher STP levels are associated with increased inflammation and with alveolar epithelial and endothelial cell injury. Methods: In 46 rats, Escherichia coli lipopolysaccharide (acute lung inflammation) or saline (control) was administered intratracheally. Both groups were protectively ventilated with inspiratory-to-expiratory ratios 1:2, 1:1, or 2:1 (n = 12 each), corresponding to low, middle, and high STP levels (STPlow, STPmid, and STPhigh, respectively). The remaining 10 animals were not mechanically ventilated. Results: In animals with mild acute lung inflammation, but not in controls: (1) messenger RNA expression of interleukin-6 was higher in STPhigh (28.1 ± 13.6; mean ± SD) and STPlow (28.9 ± 16.0) versus STPmid (7.4 ± 7.5) (P < 0.05); (2) expression of the receptor for advanced glycation end-products was increased in STPhigh (3.6 ± 1.6) versus STPlow (2.3 ± 1.1) (P < 0.05); (3) alveolar edema was decreased in STPmid (0 [0 to 0]; median, Q1 to Q3) compared with STPhigh (0.8 [0.6 to 1]) (P < 0.05); and (4) expressions of vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 were higher in STPlow (3.0 ± 1.8) versus STPhigh (1.2 ± 0.5) and STPmid (1.4 ± 0.7) (P < 0.05), respectively. Conclusions: In the mild acute lung inflammation model used herein, mechanical ventilation with inspiratory-to-expiratory of 1:1 (STPmid) minimized lung damage, whereas STPhigh increased the gene expression of biological markers associated with inflammation and alveolar epithelial cell injury and STPlow increased markers of endothelial cell damage.

Patienten, die sich einer radikalen Prostatektomie (rPE) einschlieslich retroperitonealer Lymphadenektomie (rLA) unterziehen, haben aufgrund ihres Alters und ihrer Begleiterkrankungen ein erhohtes perioperativen Risiko. Ziel dieser Untersuchung war es, den intra- und postoperativen Verlauf der standardisierten Operation rPE+rLA unter verschiedenen Anasthesieregimen zu analysieren. Krankenakten von 433 Patienten, die sich zwischen 1994 und 1999 in unserer Einrichtung einer rPE+rLA unterzogen, wurden retrospektiv ausgewertet. Die Patienten wurden nach dem durchgefuhrten Anasthesieverfahren eingeteilt: 1. Allgemeinanasthesie (AA), 2. Kombination lumbale Epiduralanasthesie (LEA)+AA, 3. thorakale Epiduralanasthesie (TEA)+AA. Fur die intra- und postoperative Katheteranalgesie wurden Bupivacain 0,25% oder Ropivacain 0,2%, 8–12 ml/h verwendet. Die Allgemeinanasthesie wurde als balancierte Anasthesie durchgefuhrt. Diese retrospektive Erhebung zeigt unter epiduraler Analgesie, gemessen an Tachykardien und hypertensiven Episoden, eine reduzierte intra- und postoperative Stressantwort, kurzere Extubationszeiten, fruheres Wiedereinsetzen der gastrointestinalen Motilitat ([h] AA: 50,6±11,1/ LEA: 39,3±13,6/ TEA:33,8±13,0), tendenziell selteneres Erbrechen und eine um einen Tag verkurzte Krankenhausverweildauer ([d] AA: 12,4±5,8/ LEA: 11,1±3,1/ TEA: 11,5±3,8). Dabei war unter TEA die Dauer der Anasthesieprasenz im OP-Bereich vergleichbar mit AA ([min] AA: 222,9±43,5/ LEA: 238,2±41,8/ TEA: 227,0±46,2), und der Wachstationsaufenthalt verkurzt. Daneben war unter TEA die Anzahl der auffalligen postoperativen Thoraxrontgenbefunde reduziert. Zum Erreichen einer der TEA vergleichbaren Analgesie mussten unter LEA haufiger sensomotorische Blockaden, saO2-Abfalle und tendenziell eine hohere Anzahl kardialer Komplikationen in Kauf genommen werden. Gemessen an den von uns erhobenen Parametern stellt damit die Kombination einer Allgemeinanasthesie, insbesondere mit thorakaler Epiduralanalgesie ein sicheres und auch betriebswirtschaftlich effizientes anasthesiologisches Vorgehen bei radikalen Prostatektomien dar.