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ZusammenfassungDie perioperative Medizin ist ein Hochrisikobereich, der besonders anfällig für Kommunikationsdefizite und -fehler ist. Das Schema „situation, background, assessment, recommendation“ (SBAR) bietet einen einfach anzuwendenden Kommunikationsleitfaden, der mit einer verbesserten Qualität der Übergabe assoziiert ist. Im März 2022 ist die Verwendung des SBAR-Schemas in der Perioperativmedizin durch die DGAI schon in zweiter Auflage empfohlen worden. Darüber hinaus hat die moderne Kommunikationsforschung ein ganzes Bündel von Maßnahmen identifiziert, die essenzielle Voraussetzungen für eine effektive Teamarbeit und die Gewährleistung der Patientensicherheit schaffen. Das SBAR-Schema ist eine Möglichkeit, strukturierte Kommunikation im klinischen Alltag umzusetzen. Entscheidend sind die konsequente Nutzung und eine klare Definition der Handlungsabläufe. Nur so können Kommunikationsdefizite in Hochrisikobereichen schneller identifiziert und durch Einführung eines strukturierten Übergabekonzeptes reduziert werden. Unabdingbar bleibt das gemeinsame Verständnis für die Notwendigkeit, diese Konzepte zu erlernen, umzusetzen und als Team zu trainieren. Das übergeordnete Ziel einer Kultur der Patientensicherheit ist nur durch die konsequente Zusammenarbeit des interprofessionellen Teams und durch das Vorleben der Führungskräfte erreichbar.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient’s preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients’ preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged. This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand. A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p

The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects.Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions.A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.HINTERGRUND: Diese Leitlinie ( http://leitlinien.net ) fokussiert ausschließlich auf den infarktbedingten kardiogenen Schock (IKS). Beide Strategien, sowohl die kardiologisch/herzchirurgische als auch die intensivmedizinische, sind zur erfolgreichen Behandlung und zum Überleben der Patienten mit IKS essenziell. Dennoch beschäftigen sich sowohl die europäischen als auch die amerikanischen Leitlinien zu Herzinfarkt und Herzinsuffizienz und auch die Positionspapiere zum kardiogenen Schock nahezu ausschließlich mit den kardiologischen Aspekten.In einem nominalen Gruppenprozess der Delegierten der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung (DGK), der Deutschen Gesellschaft für Internistische Intensiv- und Notfallmedizin (DGIIN), der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG), der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), der Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin (ÖGIAIN), der Österreichischen Kardiologischen Gesellschaft (ÖKG), der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen (DGPR) und der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) wurden unter Leitung der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) die Evidenzen zur Diagnose, zum Monitoring und zur Therapie des IKS systematisch gesammelt und – darauf aufbauend – Empfehlungen ausgearbeitet. Lag jeweils nur geringe Evidenz zum IKS vor, wurden auch Studienergebnisse generell zu Intensivpatienten gesichtet und dargestellt, um Analogieschlüsse zu erlauben.Es wurden 95 Empfehlungen – inklusive zweier Statements – erarbeitet und darauf basierend 7 Algorithmen mit konkreten Anweisungen zum Handlungsablauf.

BACKGROUND Lung ultrasound (LUS) is a point-of-care technique which can quickly identify or rule out pathological findings. To date, it is unclear if knowledge about the use of LUS is readily available. OBJECTIVES We aimed to identify how much knowledge about the use of LUS is present, if there is a need for teaching in LUS, as well as the preferred teaching method in LUS. MATERIALS AND METHODS A total of 54 participants from two university departments of anesthesiology were randomized into the groups Online, Classroom, and Control. The Online group was taught by videos, the Classroom group by a traditional lecture with hands-on training, and the Control group was not taught at all. We conducted a pre- and posttest as well as a retention test 4 weeks after the end of the study by means of a survey (comparison with Mann-Whitney U test or t‑test, respectively, with p < 0.05 considered to be significant). RESULTS LUS is used "rarely" or "never", and mainly if there is a suspicion for pleural effusion (41.3%). There is a need for LUS (Online: 21.7%; Classroom: 60.9%; Control: 62.5%, p < 0.05). Hybrid teaching consisting of classroom-based and online-based teaching is preferred by the users (Online: 52.2%; Classroom: 56.5%; Control: 62.5%). At the end of the study, 32.6% of the participants of the intervention groups had used LUS in the diagnosis of a pneumothorax. Of the participants, 93.5% planned to use LUS more often in the future. CONCLUSIONS LUS is rarely used. There is a considerable need for teaching of LUS. Internet-based teaching and traditional lectures are considered equal. Both teaching methods improve the knowledge about LUS and lead to increased use of LUS in daily practice. The participants prefer hybrid teaching incorporating both teaching methods.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

The non-opioid analgesic metamizole (dipyrone) is approved for the treatment of severe pain and is often used in the perioperative period. As it can cause agranulocytosis, a severe adverse event, its perioperative administration is controversially discussed.Is there enough evidence for a high risk of metamizol-induced agranulocytosis (MIA)? What are the consequences of its perioperative use with respect to the risk profiles of alternative analgesics?Rapid review of the literature on the risk of MIA and adverse effects of non-opioid analgesics.The incidence of MIA is estimated to be one case per million inhabitants per year. The risk seems low compared to other drugs associated with a risk of agranulocytosis, such as antithyroid drugs and ticlopidine. The risk profile of metamizole concerning hepatotoxicity, nephrotoxicity, bleeding and cardiovascular adverse effects is favorable compared to other non-opioid analgesics. None of the non-opioid analgesics are licensed to be administered intraoperatively.The perioperative use of metamizole is possible after a thorough evaluation of the indications as it provides good analgesia with a generally favorable side effect profile and is administered intravenously. The risk of agranulocytosis is small but needs to be mentioned during patient informed consent in order to optimize early recognition. Intraoperative administration aims at reducing the expected severe postoperative pain. A documentation and justification for the evaluation of the indications are recommended.

Evaluation of the patient’s medical history and a physical examination are the cornerstones of risk assessment prior to elective surgery, and may help to optimize the patient’s preoperative medical condition and guide perioperative management. Whether performance of additional technical tests (e. g., blood chemistry, electrocardiography, spirometry, chest x‑ray) can contribute to reduction of the perioperative risk is often not well known or controversial. Similarly, there is considerable uncertainty among anesthesiologists, internists, and surgeons with respect to perioperative management of the patient’s long-term medication. Therefore, the German Scientific Societies of Anesthesiology and Intensive Care Medicine (DGAI), Internal Medicine (DGIM), and Surgery (DGCH) have joined to elaborate recommendations on the preoperative evaluation of adult patients prior to elective noncardiothoracic surgery which were initially published in 2010. These recommendations have now been updated based on the current literature and existing international guidelines. In the first part, the general principles of preoperative evaluation are described (part A). The current concepts for extended evaluation of patients with known or suspected major cardiovascular disease are presented in part B. Finally, the perioperative management of patients’ long-term medication is discussed (part C). The concepts proposed in these interdisciplinary recommendations endorsed by the DGAI, DGIM, and DGCH provide a common basis for structured preoperative risk assessment and management. These recommendations aim to ensure that surgical patients undergo a rational preoperative assessment and, at the same time, aim to avoid unnecessary, costly, and potentially dangerous testing. The joint recommendations reflect the current state-of-the-art knowledge as well as expert opinions, because scientific-based evidence is not always available. These recommendations will be subject to regular re-evaluation and updating when new validated evidence becomes available. Contribution available free of charge by “Free Access”.

Clear and consistent communication is pivotal for well-functioning teamwork, in operating theatres as well as intensive care units. However, patient handovers significantly vary between specialties and locations. If communication is not well structured, it might increase the risk for mishaps and malpractice. Therefore, implementing structured handover protocols is pivotal. The perioperative setting is a high-risk environment that is prone to communication failures due to operational design (frequent change of shift due to working time restrictions) and a high work load and multitasking (operating room management, short surgery times, concurrent emergencies). Hence teamwork in the operating room and intensive care unit requires clear and consistent communication. In the perioperative setting, the patient is transferred several times: from the ward to operating room, to recovery, intermediate care/intensive care unit and back to normal ward. This necessitates multiple handovers. Since 2005, the World Health Organization (WHO) requests a structured handover concept that processes all relevant information in a predefined order. The SBAR concept (situation, background, assessment, recommendation) is an intuitive communication concept that can improve quality of patient handovers. This underlines the clinical relevance of a structured handover concept that leads to improved outcomes for every patient.In this review, basic measures for a clear and consistent communication are presented. These are pivotal for an effective teamwork and for ensuing patient safety. Furthermore, we will focus on possibilities to implement structured approaches but also on potential barriers of implementation. Communication failure among different health care providers can be identified more easily and hopefully can be eliminated.

Lung ultrasound (LUS) is a point-of-care technique which can quickly identify or rule out pathological findings. To date, it is unclear if knowledge about the use of LUS is readily available.We aimed to identify how much knowledge about the use of LUS is present, if there is a need for teaching in LUS, as well as the preferred teaching method in LUS.A total of 54 participants from two university departments of anesthesiology were randomized into the groups Online, Classroom, and Control. The Online group was taught by videos, the Classroom group by a traditional lecture with hands-on training, and the Control group was not taught at all. We conducted a pre- and posttest as well as a retention test 4 weeks after the end of the study by means of a survey (comparison with Mann-Whitney U test or t‑test, respectively, with p 0.05 considered to be significant).LUS is used "rarely" or "never", and mainly if there is a suspicion for pleural effusion (41.3%). There is a need for LUS (Online: 21.7%; Classroom: 60.9%; Control: 62.5%, p 0.05). Hybrid teaching consisting of classroom-based and online-based teaching is preferred by the users (Online: 52.2%; Classroom: 56.5%; Control: 62.5%). At the end of the study, 32.6% of the participants of the intervention groups had used LUS in the diagnosis of a pneumothorax. Of the participants, 93.5% planned to use LUS more often in the future.LUS is rarely used. There is a considerable need for teaching of LUS. Internet-based teaching and traditional lectures are considered equal. Both teaching methods improve the knowledge about LUS and lead to increased use of LUS in daily practice. The participants prefer hybrid teaching incorporating both teaching methods.

The American Society of Anesthesiologists classification of physical status (ASA PS) is a widely used system for categorizing the preoperative status of patients. The ASA class is a good independent predictor of perioperative morbidity and mortality. The definitions of the ASA classes have been amended several times since 1941, resulting in inconsistent and confusing usage in the current literature. Conflicting definitions of ASA PS exist, particularly for classes III, IV and V. The high variability of individual classifications by different anesthesiologist, however, can be explained by the previous lack of examples for diagnoses. In 2014, the ASA has added a catalogue of examples for a simplified definition for classification of the ASA PS. This has so far received limited attention in German-speaking countries. This article describes the transition of the ASA classification over the past 75 years und summarizes the currently valid definitions.

Teamwork in the operating room and in the intensive care unit necessitates clear and precise communication; however, interruptions in communication frequently occur, especially in the perioperative phase. Patient are particularly susceptible to deficits in communication due to higher stress peaks, simultaneous admission of several patients and concomitant treatment of emergency cases etc. The German Society of Anaesthesiology and Intensive Care Medicine (DGAI) therefore recommends the implementation of the so-called SBAR concept (S: "situation", B: "background", A: "assessment", R: "recommendation") for standardization of patient handover. This concept was originally developed for high-risk areas and organizations with the aim of guaranteeing a rapid, effective and consistent transfer of information.

Der Erfolg von Teamarbeit in der Notfall- und Akutmedizin, damit die Patientensicherheit, hangen neben fachlichem Konnen und Wissen ganz entscheidend von der effektiven und zielfuhrenden Kooperation und Kommunikation der einzelnen Teammitglieder ab. In der (akut-)medizinischen Ausbildung dominiert nach wie vor die Vermittlung der medizinisch-fachlichen Komponenten („technical skills“). Erst durch die ansteigende Auseinandersetzung mit dem Themenkomplex Patientensicherheit erwachst auch eine zunehmende Sensibilitat fur die Bedeutsamkeit der „human factors“. Heute ist simulatorgestutztes modulares Human-Factor-Training ein zentraler Baustein innerhalb der Masnahmen zur Entwicklung und dem Erhalt von Patientensicherheit im akutklinischen Umfeld.

There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient's individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient's risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.

Since the publication of the first german guidelines on airway management in 2014, new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

Die zu erwartende Kostensteigerung im Transfusionswesen (steigender Fremdblutbedarf bei gleichzeitig rucklaufiger Spendebereitschaft, Behandlungspflicht transfusionsassoziierter Folgeerkrankungen) erhoht den soziookonomischen Stellenwert der Entwicklung synthetischer Sauerstofftrager als Alternative zur Transfusion allogener Erythrozyten. Derzeit werden zwei Substanzgruppen im Tierexperiment und in klinischen Studien auf ihre Sicherheit und Wirksamkeit bei schwerer, transfusionsbedurftiger Anamie untersucht. Infusionslosungen auf der Basis von isoliertem menschlichem und tierischem (bovinem) Hamoglobin weisen zusatzlich zu ihrer Fahigkeit des Sauerstofftransports eine vasokonstriktorische Potenz auf, deren Bedeutung fur Organperfusion und -funktion nicht vollstandig geklart ist. Dennoch erhielt die Rinderhamoglobinlosung Hemopure® im April 2001 die Zulassung in Sudafrika. Perfluorokarbon- (PFC-)Emulsionen werden rein synthetisch hergestellt und erhohen die Loslichkeit von Sauerstoff im Plasma. Die obligate Dosislimitierung zur Vermeidung immunsuppressiver Effekte (Funktionseinschrankung von Zellen des retikuloendothelialen Systems, RES, durch Phagozytose von PFC-Emulsionstropfchen) sowie die fehlende Onkotizitat verbieten den 1:1-Ersatz von Blutverlusten durch PFC. Als Bestandteil eines multimodalen fremdblutsparenden Konzeptes, insbesondere in Kombination mit normovolamischer Hamodilution und Hyperoxie, kann die niedrig-dosierte Bolusanwendung der PFC-Emulsion Oxygent® die intraoperative Anamietoleranz steigern. Obwohl mit beiden Substanzgruppen, Hamoglobinlosungen und PFC, die Reduktion perioperativer Fremdbluttransfusionen bereits in einzelnen klinischen Studien nachgewiesen werden konnte, ist ihre Einfuhrung in die breite klinische Praxis derzeit nicht absehbar.

Eine Storung der rechtsventrikularen (RV) Funktion ist meist Folge einer pulmonalen Hypertension oder myokardialen Minderperfusion. Sie ist gekennzeichnet durch eine RV Dilatation mit Anstieg von Wandspannung und O2-Verbrauch bei reduzierter Ejektionsfraktion („Dysfunktion“). Kommt es zum Abfall von arteriellem Druck und koronarem Perfusionsdruck, kann dies ein RV-Versagen mit Schock auslosen („Insuffizienz“). Diagnostik und Monitoring des RV sind schwierig, eine RV Dysfunktion bleibt daher haufig unbemerkt oder wird fehlgedeutet. Eine kausale Therapie ist nur selten moglich. Die symptomatische Therapie der RV-Insuffizienz stutzt sich auf vier Prinzipien: 1) Optimierung der Vorlast: Der insuffiziente RV benotigt zur Aufrechterhaltung seines Schlagvolumens eine gute Fullung. Andererseits kann eine Uberdehnung des RV eine Myokardischamie induzieren. Eine adaquate Volumentherapie ist daher essentiell, muss jedoch unter engmaschigem hamodynamischem Monitoring erfolgen. 2) Aufrechterhaltung des Aortendrucks: Bei kritischem Abfall des arteriellen Drucks sind Vasopressoren indiziert, um den RV Perfusionsdruck zu erhohen. Noradrenalin gilt wegen seiner zusatzlich positiv inotropen Wirkung als Mittel der Wahl. 3) Verminderung der Nachlast: Wahrend sich intravenose Vasodilatatoren wegen systemischer Nebenwirkungen nur bedingt zur Therapie der pulmonalen Hypertension eignen, dilatieren inhalierte Vasodilatatoren die Lungenstrombahn selektiv und verbessern so die Pumpfunktion des RV. 4) Steigerung der Kontraktilitat: Mittel der Wahl bei Dekompensation und Schock sind Noradrenalin und Adrenalin. Inodilatatoren wirken positiv inotrop und pulmonal vasodilatierend. Sie eignen sich daher ebenfalls zur Therapie, sollten jedoch wegen der Gefahr der Hypotension nur bei kreislaufstabilen Patienten eingesetzt werden.

Besides sophisticated ventilatory management and physical measures (e.g., prone position) a variety of different pharmacological strategies are presently being used to improve pulmonary function in patients with acute respiratory distress syndrome (ARDS). In this review, current data are discussed with respect to the use of β2-mimetics, cyclooxygenase inhibitors, glucocorticoids, antioxidants, and mucolytics. Furthermore, the role of nutrition and topical antibiotics is discussed. Although animal experiments and clinical studies suggest that some beneficial effects can be achieved by each of these concepts, no conclusive evidence has been provided up to now that these concepts reduce morbidity and mortality of patients suffering from severe ARDS.

The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine on preoperative evaluation of adult patients prior to elective, non-cardiac surgery published in November 2010 were the first practical and comprehensive guidelines for preoperative evaluation available to anesthetists in Germany.This study was carried out to analyze the state of implementation of these guidelines into clinical practice as well as changes in strategies for assessing perioperative risk from the viewpoint of anesthesia personnel in Germany.A 25-item questionnaire concerning general characteristics of workplaces, cognizance, reasonability and convenience of the joint recommendations was developed as an online survey. Furthermore, changes in strategies for preoperative evaluation were polled.A total of 1,840 anesthetists completed the questionnaire. The results showed that 84.2 % were acquainted with the joint recommendations, 57.3 % evaluated them as completely reasonable and 18.2 % as partly reasonable. A total of 71.4 % indicated that the joint recommendations were implemented completely or partly in their department strategies for preoperative evaluation. From the viewpoint of personnel, anamnesis and physical examination were performed more frequently by 25.7 % while routine diagnostic testing was ordered less frequently by 39.1 %. Advantages by implementing the joint recommendations (e.g. simplification for medical staff and patients, decrease of costs, reduction of radiological examinations) were seen by 45.5 %. Problems, such as increasing expenditure of time and personnel due to implementation were mentioned by 20.3 %.The joint recommendations are well known and positively rated among anesthetists in Germany responding to the questionnaire reflecting an effective implementation process over the last 2 years. The anesthetists who completed the questionnaire stated that the use of the recommendations leads to a more reasonable approach in preoperative risk evaluation which contributes to an increase in patient safety and satisfaction.

Radioactive microspheres (MS) injected into the systemic circulation shunt to the venous side of the circulation and are trapped in the lung vasculature. We hypothesized that regional pulmonary perfusion could be determined by using systemically injected shunted MS. In seven anesthetized mechanically ventilated foxhounds, regional pulmonary perfusion was measured at baseline and during experimental acute respiratory distress syndrome with MS injected into both the right and left atrium (protocol 1). Methodological error of the MS technique was assessed by simultaneous injection of two different batches of MS into the right atrium (protocol 2). Measurement of perfusion during baseline and during experimental acute respiratory distress syndrome with shunted MS had a mean bias of 0.8 and 5.6% and mean precision of 19.2 and 34.7% (r = 0.94 and r = 0.95), respectively, compared with data from nonshunted MS. Simultaneous perfusion measurements displayed bias of -2.7 and 6% and precision of 8.2 and 5.3% (r = 0.98 and r = 0.99), respectively. Systemic shunt should be high for this method to prevent bronchial circulation from imposing significant error. We conclude that systemically injected MS can be used for simultaneous measurement of regional systemic and regional pulmonary perfusion, provided that MS that shunted in the first pass are measured in lung tissue.

In 2009 and 2011 all German physicians authorized to provide postgraduate training (WBB) and physicians in postgraduate training (WBA) were invited to participate in a survey focusing on various aspects of postgraduate training. The survey was initiated by the German Medical Council and the contents and underlying methodology were based on a survey carried out annually in Switzerland.The response rate of WBAs from 2009 and 2011 increased from 32.8 % to 38.6 % (n = 20.518) while the response rate of WBBs decreased from 60.8 % to 53.3 % (n = 9,276). Anesthesiologists (both WBB and WBA) participated more frequently compared to other disciplines (WBB 74.3 % versus 53.3 %, WBA 45.6 % versus 38.6 %). The quality of postgraduate training was evaluated on a scale from 1 to 6, with 1 as the best and 6 as the worst evaluation result. In 2009 the overall evaluation was rated as satisfying (2.54) and in 2011 there was a tendency towards improvement (2.44) with the overall result for postgraduate training quality in anesthesiology (2.44) lying exactly within the average of all disciplines. In the section critical incident management anesthesiology was assessed as being above average, whereas it was below average in the topics professional competence and decision-making culture. In terms of job situation (e.g. structure of training, off-duty after on-call duty and documentation and remuneration of overtime), anesthesiology was assessed as being above average. Although collected these data were, however, not included in the statistical analysis of the overall data set. Noteworthy was that WBBs rated the quality of postgraduate training better than WBAs (the delta being 0.66 on average over all 8 items assessed). Postgraduate training in ambulatory settings (WBS) with outpatient medical service was scored much better than average by WBAs (1.7 versus 2.44).The current survey gives an insight into the assessment of over 9,000 physicians authorized to provide postgraduate training in Germany and over 20,000 physicians in training programs. While the comparison between the different medical disciplines within each survey appears to be valid the comparison between the results of the 2009 and 2011 surveys needs to be critically evaluated due to some inhomogeneities in the collectives. A higher than average participation of anesthesiologists indicates a notable willingness to contribute to measures aiming at the improvement of postgraduate training. It is difficult to assess the extent to which the data obtained in this evaluation reliably reflect the quality of postgraduate training in German medical institutions. Nevertheless, the survey provides valuable information about targeted attempts for improvement. Obvious potential for improvement can be seen not only within the scope of structural quality (training plan and target) but also in feedback. Personal contact to persons authorized to provide postgraduate training seems to have a very positive effect on the result of the evaluation. The results concerned with job situation, which were above average for anesthesiology, was not included in the evaluation performed by the German Medical Council and hence had no chance to positively influence the overall result. These results should be included in the evaluation of future surveys dealing with postgraduate training quality.

While assessing the medical history and physical examination are the cornerstones of preoperative risk evaluation, the importance of "routine" testing has been critically discussed in recent studies. The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine for preoperative evaluation of adult patients prior to elective, non-cardiac surgery, which were published in November 2010, are the first comprehensive practice guidelines for preoperative evaluation in Germany. Aim of this study was to analyze former strategies for assessing perioperative risk at anaesthesia departments in Germany.A 29-item questionnaire concerning general hospital characteristics, strategies for preoperative evaluation and cognizance of the joint recommendations was developed as an online survey. In particular the reasons for technical assessment were surveyed (i.e. routine, patient age or pre-existing conditions, risk of operation being performed). In certain questions multiple answers were permitted. All hospitals with departments of anaesthesiology in Germany were included. Data are presented as percentages.A total of 396 hospitals (35.6%) completed the questionnaire. Physical examination is not performed regularly (37%) but only when indicated by the medical history. Criteria for performing preoperative electrocardiograms are comorbidities of the cardiovascular (80.1%) and pulmonary systems (42.2%) as well as patient age (52.8%) and as routine measures (10.1%). Laboratory testing was performed as a routine (43.2%) because of patient age (52.8%) or pre-existing conditions (37.3%). Preoperative chest x-ray was carried out when the medical history or physical examination suggest intrathoracic pathologies (81.3%) or was based on patient age (35.9%). The majority of hospitals (89.1%) plan to implement the joint recommendations for preoperative evaluation in the future.According to the joint recommendations preoperative testing is more and more directed to patients with an increased perioperative risk which is clinically indicated by medical history and physical examination. However, routine or age-related medical testing is still a frequently used strategy. German medical societies should focus on advanced implementation strategies to change current practices in order to avoid unnecessary diagnostic procedures and to increase patient safety and satisfaction.

Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.

In patients with coronary stents scheduled for surgery the question arises whether and how antiplatelet therapy should be continued. Risks of perioperative bleeding and of acute stent thrombosis have to be considered simultaneously. The bleeding risk depends primarily on the kind of surgery and on patient comorbidity. The risk of stent thrombosis is increased in these patients due to the thrombogenic surface of the stents. The main determinants are hereby the time duration after stent implantation, the kind of the stent [uncoated (bare-metal stent, BMS) or coated (drug-eluting stent, DES)], as well as angiographic and clinical patient factors. Therefore, perioperative antiplatelet therapy has to be individually adapted for each patient. Bridging with heparin is ineffective. Bridging with intravenous antiplatelet drugs during the perioperative interruption of oral antiplatelet therapy might be a potential procedure in high-risk patients. Whether bedside monitoring of antiplatelet therapy improves the perioperative management of these patients and reduces adverse outcome is object of current studies.

Zusammenfassung Mit dem Auftreten der Neuen Influenza A/H1N1 2009 als Pandemie hat auch in Deutschland die Zahl der Neuerkrankungen rasch zugenommen. Nach wie vor zeigen die meisten Erkrankten eine milde Ausprägung. In Einzelfällen kommt es jedoch zu schweren Verläufen, die eine stationäre oder intensivmedizinische Behandlung erfordern. Während mittlerweile für die Behandlung von Patienten mit A/H1N1v-Infektion im ambulanten und allgemeinstationären Bereich zahlreiche Empfehlungen und Stellungnahmen vorliegen, ergeben sich bei erforderlicher Intensivbehandlung teilweise vollkommen neue Fragestellungen. Nachfolgend wird daher auf dem Boden der aktuellen Literatur, eigener Erfahrungen und einschlägiger Empfehlungen von Gesundheitsbehörden das Vorgehen bei Patienten mit schwerem intensivpflichtigen Verlauf einer A/H1N1v-Infektion dargestellt. Bereits aus Anamnese und zeitlichem Verlauf der Symptome ergeben sich erste wichtige Schlussfolgerungen hinsichtlich weiterer therapeutischer und hygienischer Maßnahmen. Das Verfahren der Wahl zum diagnostischen Nachweis von A/H1N1v ist die Polymerase-Kettenreaktion (PCR). Liegen bestimmte Risikofaktoren vor (z. B. Schwangerschaft, Immunsuppression, Adipositas), steigt die Wahrscheinlichkeit eines schweren Verlaufs der Influenza A/H1N1v 2009. Noch bevor die Testergebnisse vorliegen, sollten daher bei begründetem Verdacht die antivirale Therapie eingeleitet und Isolations- bzw. Personalschutzmaßnahmen getroffen werden. Die weitere intensivmedizinische Therapie zielt auf die Beherrschung begleitender Organkomplikationen ab (z. B. nichtinvasive bzw. maschinelle Beatmung bei drohender Hypoxämie). Zur Vermeidung einer bakteriellen Sekundärinfektion ist bei schwerer respiratorischer Insuffizienz frühzeitig eine kalkulierte antiinfektive Therapie indiziert. In Anbetracht der hohen Dynamik bei der Entwicklung einer respiratorischen Insuffizienz kann eine extrakorporale Membranoxygenierung notwendig werden. In diesem Fall sollte frühzeitig mit einem entsprechenden Zentrum Kontakt aufgenommen werden.