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Background: The aim of our study was to analyze perioperative lactate levels and their predictive value for postoperative mortality and morbidity after liver resection. Methods: The clinicopathological characteristics and outcomes of 152 patients who underwent liver resection for benign and malign diagnoses were analyzed retrospectively. Lactate concentrations at three different time points, (1) before liver resection (LAC-PRE), (2) after liver resection on day 0 (LAC-POST), and (3) on day one after the operation (LAC-POD1) were assessed regarding the prognostic value in predicting postoperative complications and mortality according to the Clavien–Dindo (CD) classification. Results: The rates of postoperative complications (CD ≥ IIIb) and mortality rates were 19.7% (N = 30) and 4.6% (N = 7), respectively. The LAC-PRE levels showed no correlation with the postoperative outcome. The ROC curve analysis showed that LCT-POST and LCT-POD1 values were moderately strong in predicting postoperative morbidity (0.681 and 0.768, respectively) and had strong predictive accuracies regarding postoperative mortality (0.800 and 0.838, respectively). The multivariate analysis revealed LAC-POST as a significant predictor of postoperative complications (CD ≥ IIIb: OR 9.28; 95% CI: 2.88–29.9; p < 0.001) and mortality (OR 11.69; 95% CI: 1.76–77.7; p = 0.011). Conclusion: Early postoperative lactate levels are a useful and easily practicable predictor of postoperative morbidity and mortality in patients after liver resection.

ZusammenfassungDie Ösophagusatresie (ÖA) ist eine angeborene Kontinuitätsunterbrechung der Speiseröhre mit oder ohne Fistel zur Trachea (Tracheoösophageale Fistel, TÖF). Je nach Abstand zwischen den beiden Ösophagusenden unterscheidet man eine „kurzstreckige“ von einer „langstreckigen“ Form. Bis zu 50% der Neugeborenen weisen weitere Anomalien auf. Eine pränatale Diagnose der ÖA gelingt in 32–63% der Fälle. Die interdisziplinäre Betreuung dieser Kinder hat sich in den letzten Jahren gewandelt. In der folgenden Arbeit wird die aktuelle S2K-Leitlinie der Deutschen Gesellschaft für Kinderchirurgie zur Behandlung der ÖA mit unterer TÖF, die etwa 90% aller Fälle ausmacht, zusammengefasst. Hierzu gehören das präoperative Management sowie operative und anästhesiologische Aspekte (u. a. Thorakoskopie vs. Thorakotomie, präoperative Tracheobronchoskopie, intraoperative Hyperkapnie und Azidose). Ferner wird das postoperative Management insbesondere von relevanten Komplikationen wie der Anastomosenstenose beschrieben. Trotz Fortschritten in der Behandlung der ÖA ist die Langzeitmorbidität mit Motilitätsstörungen des Ösophagus, gastroösophagealer Refluxkrankheit, rezidivierenden Infektionen der oberen und unteren Atemwege, Tracheomalazie, mangelhaftem Gedeihen sowie orthopädischen Problemen nach Thorakotomie weiterhin hoch. Zum Erreichen einer guten Lebensqualität ist daher eine gute interdisziplinäre Nachsorge wichtig.

Background/AimsAim of our study was to analyze surgical parameters and postoperative morbidity with special emphasis on cut surface biliary leakage (BL), after launching a minimally invasive liver resection program at our center.Patients and methodsA prospectively maintained medical database of patients who required liver resection was used for analysis. Exclusion criteria were liver resections with biliodigestive anastomosis. Clinicopathological characteristics and outcomes were analyzed retrospectively.ResultsA total of 141 patients were divided into a group of 47 patients (33.3%) receiving laparoscopic (LLR) and 94 patients (66.7%) undergoing open liver resections (OLR). We performed 62 major OLR (66.0%) and 31 major LLR (66.0%). In comparison with the LLR group, operation time was longer (326 ± 97 minutes vs. 287 ± 133 minutes; P = 0.080) and average blood loss was higher in the OLR group (529 ± 441 mL vs. 356 ± 459 mL; P = 0.052), without showing significancy. In the LLR group, morbidity was significantly lower than in the OLR group (OLR vs. LLR: 19 (20.2 %) vs. 3 (6.4%); P = 0.033). Overall BL rate was 4.3% (N = 6). All BL occurred in patients after OLR and were associated with a significantly longer hospital stay (hospital stay with biliary leakage vs. hospital stay without biliary leakage: 37.3 ± 19.3 days vs. 14.7 ± 11.1 days; P < 0.001).ConclusionThe introduction of different transection techniques in laparoscopic liver resections did not increase morbidity and BL rate.

Background/AimsBiliary leakage (BL) is a major cause of postoperative morbidity after liver resection. Aim of our study was to analyse surgical parameters and postoperative morbidity with special emphasis on BL, after launching a minimally invasive liver resection program.MethodsA prospectively maintained medical database of patients who required a liver resection was used for analysis.ResultsA total of n=156 patients were divided into a group of n=47 patients (30.1%) receiving laparoscopic (LLR) and n=109 patients (69.9%) undergoing open liver resections (OLR). Patient age (OLR: 59.4 ± 16.0 vs. LLR: 57.9 ± 14.2 years) and male to female ratio (OLR: 63/46 vs. LLR: 25/22) were comparable. We performed n=75 (68.8%) major OLR and n=31 (66.0%) major LLR. Operation time was OLR 342.8 ± 110.5 min vs. LLR 287.3 ± 132.6 min (p=0.014) and the average blood loss was OLR 523.5 ± 428.6 ml vs. LLR 355.5 ± 459.2 ml. Morbidity and mortality was observed in n= 29 (18.6 %) and n= 7 (4.5 %) patients, respectively. The overall biliary leakage (BL) rate was 5.1% (n= 8). Majority of BL were detected in OLR with biliodigestive anastomosis (BDA) (n=2 (11.0%)) followed by OLR without BDA (n=6 (6.5%)). No BL were detected in patients with LLR. Hospital stay was significantly prolonged after OLR in patients with BL (38.4 ± 20.1 vs. 17.4 ± 11.1 days, p< 0.001).ConclusionIn line with previous reports, the introduction of different transection techniques in laparoscopic liver resections did not increase morbidity and BL-rate.

Esophageal atresia (EA) is a congenital anomaly that entails an interrupted esophagus with or without tracheoesophageal fistula (TEF). Depending on the distance of the two esophageal pouches a "short-gap" is distinguished from a "long-gap" variant. Up to 50% of newborns have additional anomalies. EA is prenatally diagnosed in 32-63% of cases. Recently, the interdisciplinary care in these children underwent substantial changes. Therefore, we summarize the current guideline of the German society of pediatric surgery for the treatment of patients with EA and distal TEF (Gross Type C). Controversies regarding the perioperative management include surgical-technical aspects, such as the thoracoscopic approach to EA, as well as general anesthesia (preoperative tracheobronchoscopy, intraoperative hypercapnia and acidosis). Moreover, postoperative complications and their management like anastomotic stricture are outlined. Despite significant improvements in the treatment of EA, there is still a relevant amount of long-term morbidity after surgical correction. This includes dysmotility of the esophagus, gastroesophageal reflux disease, recurrent respiratory infections, tracheomalacia, failure to thrive, and orthopedic complications following thoracotomy in the neonatal age. Therefore, close follow-up is mandatory to attain optimal quality of life.Die Ösophagusatresie (ÖA) ist eine angeborene Kontinuitätsunterbrechung der Speiseröhre mit oder ohne Fistel zur Trachea (Tracheoösophageale Fistel, TÖF). Je nach Abstand zwischen den beiden Ösophagusenden unterscheidet man eine „kurzstreckige“ von einer „langstreckigen“ Form. Bis zu 50% der Neugeborenen weisen weitere Anomalien auf. Eine pränatale Diagnose der ÖA gelingt in 32–63% der Fälle. Die interdisziplinäre Betreuung dieser Kinder hat sich in den letzten Jahren gewandelt. In der folgenden Arbeit wird die aktuelle S2K-Leitlinie der Deutschen Gesellschaft für Kinderchirurgie zur Behandlung der ÖA mit unterer TÖF, die etwa 90% aller Fälle ausmacht, zusammengefasst. Hierzu gehören das präoperative Management sowie operative und anästhesiologische Aspekte (u. a. Thorakoskopie vs. Thorakotomie, präoperative Tracheobronchoskopie, intraoperative Hyperkapnie und Azidose). Ferner wird das postoperative Management insbesondere von relevanten Komplikationen wie der Anastomosenstenose beschrieben. Trotz Fortschritten in der Behandlung der ÖA ist die Langzeitmorbidität mit Motilitätsstörungen des Ösophagus, gastroösophagealer Refluxkrankheit, rezidivierenden Infektionen der oberen und unteren Atemwege, Tracheomalazie, mangelhaftem Gedeihen sowie orthopädischen Problemen nach Thorakotomie weiterhin hoch. Zum Erreichen einer guten Lebensqualität ist daher eine gute interdisziplinäre Nachsorge wichtig.

ZusammenfassungDas pädiatrische Emergence Delir rückt aufgrund der Debatte um Neurotoxizität von Anästhetika bei kleinen Kindern erneut in den Fokus. Die 2017 von der Europäischen Gesellschaft für Anästhesiologie (ESA) publizierte Leitlinie zu Prävention und Therapie kann eine sinnvolle Unterstützung der klinischen Tätigkeit sein. Insbesondere die zügige und konsequente Behandlung von Schmerzen bei kleinen Kindern und die konsequente Diagnose eines pädED mittels validierter Skale ermöglicht es- dank der Verbreitung von patient data management systemen- in Zukunft eine reelle Inzidenz des pädEDs anzugeben. In der Prävention des pädED liegt der Schwerpunkt auf der Reduktion der präoperativen Angst der Kinder, egal, ob dies durch ein auf das Kind fokussierte Kinderanästhesieteam zusammen mit den Eltern, Musik, Clowns, smartphones/tablets oder eine medikamentöse Prämedikation erzielt wird. Medikamentöse pädED-Prophylaxe durch perioperative Anwendung von alpha-2-Agonisten und die Verwendung von Propofol als Ausleitungsbolus oder TIVA erscheint gleichzeitg sinnvoll. Postoperativ ermöglicht eine ruhige Aufwachumgebung ein entspanntes delirfreies Aufwachen. Postanästhesiologische Visiten mit strukturiertem Erfassen von Veränderungen des kindlichen Verhaltens respektive schriftliche Fragebögen werden in Zukunft Auskunft über das pädED auf den Normalstationen geben. Strukturierte Nachbefragungen im Verlauf werden auch die Erfassung postoperativen unerwünschten Verhaltensänderungen und deren möglichen Zusammenhang zum pädED ermöglichen.

In March 2019 the HADES experiment recorded 14 billion Ag+Ag collisions at √sNN = 2.55 GeV as a part of the FAIR phase-0 physics program. In this contribution, we present and investigate our capabilities to reconstruct and analyze weakly decaying strange hadrons and hypernuclei emerging from these collisions. The focus is put on measuring the mean lifetimes of these particles.

Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.

The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration.To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy.Randomised, controlled, blinded and single-centre study.Academic tertiary care centre in Leipzig from April 2014 to May 2015.It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway.All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation.The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy.In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group.Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy.DRKS00008985 (German Clinical Trials Register).

Kindernotfalle sind im Bereich der praklinischen Notfallmedizin seltene Ereignisse und u. a. deshalb fur Notarzte und Rettungsdienstkrafte oft mit Stress und Unsicherheit verbunden. Es existiert eine Vielzahl verschiedener kognitiver Hilfsmittel (Bucher, Apps, Lineale, gewichtsadaptierte Taschensysteme etc.), um im padiatrischen Notfall die adaquate Versorgung sicherzustellen. Insbesondere die richtige Grosenauswahl der Ausrustung und die Dosierung der Notfallmedikamente sind bei Kindern individuell sehr unterschiedlich und abhangig von Kenngrosen wie der Korperlange und dem Korpergewicht. Kognitive Hilfsmittel beinhalten deshalb oftmals die Moglichkeit der Langenmessung, von der wiederum auf das Gewicht als Leitwert zur Dosisberechnung von Medikamenten ruckgeschlossen werden kann. Zwar konnen diese Hilfsmittel die Fehldosierung und -behandlung von Kindern im Notfall verhindern helfen, ihr unkritischer und nicht im Vorfeld trainierter Einsatz birgt aber auch die Gefahr der falschen Anwendung. Diese Empfehlung bietet einen Uberblick uber die allgemeinen Anforderungen und Probleme verschiedener Arten kognitiver Hilfsmittel und soll dazu beitragen, die Rahmenbedingungen und die rationale Basis fur den Einsatz und die Weiterentwicklung kognitiver Hilfsmittel in der Notfallmedizin zu verbessern.

The growing number of medical procedures performed in children that require cooperation of patients, lack of movement, anxiolysis or/and analgesia triggers the increased need for procedural sedation. This document presents the consensus statement of the European Society for Paediatric Anaesthesiology about the principles connected with the safe management of procedural sedation and analgesia (PSA) by anaesthesiologists for elective procedures in children. It does not aim to provide a legal statement on how and by whom PSA should be performed. The document highlights that any staff taking part in sedation of children must be appropriately trained with the required competencies and must be able to demonstrate regularly that they have maintained their knowledge, skills and clinical experience. The main goal of creating this document was to reflect the opinions of the community of the paediatric anaesthesiologists in Europe regarding how PSA for paediatric patients should be organized to make it safe.

Ubergewicht und Adipositas sind in der Kinderanasthesie zunehmend relevant. In der vorliegenden Arbeit wurde untersucht, inwiefern ubergewichtige Kinder und Jugendliche Atemwegskomplikationen wahrend einer Allgemeinanasthesie aufweisen und welche Bedeutung die Thematik in der lokalen Population hat. Von Oktober 2008 bis August 2009 wurden am Universitatsklinikum Leipzig ambulante und stationare Patienten wahrend eines Elektiveingriffs (2–18 Jahre, ASA I–III, Kinderchirurgie und Hals-Nasen-Ohren-Heilkunde, insgesamt 504 Patienten) betrachtet. Mithilfe spezieller Erfassungsbogen wurden folgende Parameter ermittelt: der Mallampati-Score, schwierige Maskenventilation und Intubation, die Verwendung eines Atemwegshilfsmittels, der Cormack-Lehane-Score und die Anzahl der Intubationsversuche; des Weiteren die Inzidenz von Atemwegsobstruktionen (Broncho- und Laryngospasmen) und Husten als Zeichen der Atemwegsirritation und Sauerstoffsattigungsabfalle >10 % des Ausgangswerts. Es zeigte sich ein signifikant hoherer Mallampati-Score und ein signifikant haufigeres Auftreten von Husten (p < 0,05). Die weiteren Parameter blieben ohne statistisch relevanten Unterschied. Die Inzidenz von Sauerstoffsattigungsabfallen war 9,5 % bei den Ubergewichtigen und 6,3 % bei den Normalgewichtigen und die Inzidenz von Atemwegsobstruktionen betrug 4,1 % bzw. 2,7 %. Die Inzidenz von respiratorischen Komplikationen ist in der vorliegenden Studie insgesamt gering. Ursache dafur konnen der geringe Anteil von morbid adiposen Kindern und das hohere Alter der ubergewichtigen Kinder im Vergleich zu anderen Studien sein.

Die Moglichkeiten des Monitorings der Hamodynamik und zerebralen Perfusion sind in der Kinderanasthesie aufgrund der geringen technischen Vielfalt eingeschrankt. Dieses Monitoring sollte jedoch vor dem Hintergrund des potenziellen Schadens einer langanhaltenden Hypotension und zerebralen Minderperfusion zum Einsatz kommen. So steht derzeit fur die breite Anwendung die nicht invasive Blutdruckmessung und fur Risikopatienten v. a. die Nahinfrarot-Spektroskopie zur Verfugung. Die fruhzeitige Messung des Blutdrucks und die Beachtung der Grenzen standen in der Vergangenheit in der Kinderanasthesie im Hintergrund. Das ist aufgrund der aktuellen Datenlage nicht mehr state of the art.

Notfalle mit Kindern machen ca. 5–10% aller praklinischen Notfalle aus. Invasive Masnahmen zur Sicherung der Atemwege sind davon in weniger als 5% notig [1,2]. Nicht zuletzt aufgrund der insgesamt geringen Inzidenz stellt die Atemwegssicherung bei Kindern daher fur viele praktizierende Notfallmediziner und Rettungskrafte eine grose Herausforderung dar. Es fehlt an der notwendigen Routine im Umgang mit kindlichen Atemwegen bei einer gleichzeitig hohen emotionalen Belastung.

The upcoming and ongoing debate on neurotoxicity of anesthetics at a young age put a new spotlight on the emergence delirium of children (paedED). The European Society for Anesthesiology published a consensus guideline on prevention and therapy in 2017 which can be a useful guidance in daily clinical practice. Patient data management systems with their clear documentation concerning pain/therapy of pain and paedED will be valuable tools in order to assess the real incidence of paedED. Differentiating between pain/agitation and paedED migth not always be easy. Age-adapted scores should always be applied. Main focus in the prevention of paedED is the reduction of anxiety. The way this is achieved by the dedicated pediatric anesthesia teams caring for children, e.g. by oral midazolam, clowns, music, smartphone induction, does not matter. Using αDas pädiatrische Emergence Delir rückt aufgrund der Debatte um Neurotoxizität von Anästhetika bei kleinen Kindern erneut in den Fokus. Die 2017 von der Europäischen Gesellschaft für Anästhesiologie (ESA) publizierte Leitlinie zu Prävention und Therapie kann eine sinnvolle Unterstützung der klinischen Tätigkeit sein. Insbesondere die zügige und konsequente Behandlung von Schmerzen bei kleinen Kindern und die konsequente Diagnose eines pädED mittels validierter Skale ermöglicht es- dank der Verbreitung von patient data management systemen- in Zukunft eine reelle Inzidenz des pädEDs anzugeben. In der Prävention des pädED liegt der Schwerpunkt auf der Reduktion der präoperativen Angst der Kinder, egal, ob dies durch ein auf das Kind fokussierte Kinderanästhesieteam zusammen mit den Eltern, Musik, Clowns, smartphones/tablets oder eine medikamentöse Prämedikation erzielt wird. Medikamentöse pädED-Prophylaxe durch perioperative Anwendung von alpha-2-Agonisten und die Verwendung von Propofol als Ausleitungsbolus oder TIVA erscheint gleichzeitg sinnvoll. Postoperativ ermöglicht eine ruhige Aufwachumgebung ein entspanntes delirfreies Aufwachen. Postanästhesiologische Visiten mit strukturiertem Erfassen von Veränderungen des kindlichen Verhaltens respektive schriftliche Fragebögen werden in Zukunft Auskunft über das pädED auf den Normalstationen geben. Strukturierte Nachbefragungen im Verlauf werden auch die Erfassung postoperativen unerwünschten Verhaltensänderungen und deren möglichen Zusammenhang zum pädED ermöglichen.

This consensus- based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re-establish the child's normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid- base- electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1-2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

Options for hemodynamic and cerebral perfusion monitoring in pediatric anesthesia are limited, but it should be used to reduce the potential damage due to hypotension and reduced cerebral perfusion. Non-invasive blood pressure measurement should be used in all cases of pediatric anesthesia and near-infrared spectroscopy for risk pediatric patients. In former times measurement of non-invasive blood pressure had no priority, this is not state of the art based on current data.

To test the compensatory role of endothelin-1 when acute blood loss is superimposed on anaesthesia, by characterizing the effect of systemic endothelin receptor subtype A (ET(A)) blockade on the haemodynamic and hormonal responses to haemorrhage in dogs anaesthetized with xenon/remifentanil (X/R) or isoflurane/remifentanil (I/R).Prospective experimental randomized controlled study.Six female Beagle dogs, 13.4 +/- 1.3 kg.Animals were anaesthetized with remifentanil 0.5 microg kg(-1) minute(-1) plus either 0.8% isoflurane (I/R) or 63% xenon (X/R), with and without (Control) the systemic intravenous endothelin receptor subtype A antagonist atrasentan (four groups, n = 6 each). After 60 minutes of baseline anaesthesia, the dogs were bled (20 mL kg(-1)) over 5 minutes and hypovolemia was maintained for 1 hour. Continuous haemodynamic monitoring was performed via femoral and pulmonary artery catheters; vasoactive hormones were measured before and after haemorrhage.In Controls, systemic vascular resistance (SVR), vasopressin and catecholamine plasma concentrations were higher with X/R than with I/R anaesthesia at pre-haemorrhage baseline. The peak increase after haemorrhage was higher during X/R than during I/R anaesthesia (SVR 7420 +/- 867 versus 5423 +/- 547 dyne seconds cm(-5); vasopressin 104 +/- 23 versus 44 +/- 6 pg mL(-1); epinephrine 2956 +/- 310 versus 177 +/- 99 pg mL(-1); norepinephrine 862 +/- 117 versus 195 +/- 33 pg mL(-1), p0.05). Haemorrhage reduced central venous pressure from 3 +/- 1 to 1 +/- 1 cm H(2)O (I/R, ns) and from 8 +/- 1 to 5 +/- 1 cm H(2)O (X/R, p0.05), but did not reduce mean arterial pressure, nor cardiac output. Atrasentan did not alter the haemodynamic and hormonal response to haemorrhage during either anaesthetic protocol.Selective ET(A) receptor blockade with atrasentan did not impair the haemodynamic and hormonal compensation of acute haemorrhage during X/R or I/R anaesthesia in dogs.

The incidence of overweight and obesity in children and adolescents who need an anesthesia is increasing. These children have a higher risk for perioperative complications. The review discusses definition and causes of obesity in children, gives information about relevant pathophysiological changes, and focuses anesthesiological management and complications.

The increase in intra-abdominal pressure may be followed by a renal, gut, respiratory and cardial dysfunction and an increase in intra-cranial pressure. The review focuses risk factors and pathophysiological consequences of intra-abdominal hypertension and of abdominal compartment syndrome. Patients with intra-abdominal hypertension and abdominal compartment syndrome are critical ill and need special anesthesiological care due to risk of pulmonary aspiration, hemodynamic disturbances and difficult mechanical ventilation.

In congenital hyperinsulinism (CHI), the identification and precise localization of a focal lesion is essential for successful surgery.Our objective was to evaluate the predictive value and accuracy of integrated [18F]fluoro-L-DOPA ([18F]FDOPA) positron emission tomography (PET)-computed tomography (CT) for the surgical therapy of CHI.This was an observational study.The study was performed in the Department of Pediatric Surgery at a university hospital.From February 2005 to September 2007, 10 children with the clinical signs of CHI and an increased radiotracer uptake in a circumscribed area of the pancreas in the [18F]FDOPA PET-CT were evaluated.Guided by the [18F]FDOPA PET-CT report, all children underwent partial pancreatic resection, in two cases twice.Correlation of the anatomical findings at surgery with the report of the [18F]FDOPA PET-CT, and the results of surgery and clinical outcome were determined.In nine children the intraoperative situation corresponded exactly to the description of the [18F]FDOPA PET-CT. A limited resection of the pancreas was curative in eight cases at the first surgery, in one case at the second intervention. We observed no diabetes mellitus or exocrine insufficiency in the follow up so far. In one child, hypoglycemia persisted even after two partial resections of the pancreatic head. Histological analysis finally revealed an atypical intermediate form of CHI.The integrated [18F]FDOPA PET-CT is accurate to localize the lesion in focal CHI and is a valuable tool to guide the surgeon in limited pancreatic resection.

Cardiopulmonary resuscitation of a child is a rare, emotionally affective, challenging and potentially frightful event. Current guidelines have been largely simplified to facilitate teaching and retention, to encourage bystander resuscitation, and to improve the quality of resuscitation by healthcare professionals. This article is a practical approach to the current european guidelines (ERC), including basic and advanced life support algorithms, as well as recommendations on the post-resuscitation periode and parental presence.

Regional anesthesia has many advantages as intraoperative and more important as postoperative analgesia in pediatric anesthesia. There are special requirements for a sufficient acute pain management in preterms, newborns and small infants. This review focuses these special features regarding to local anesthetics and supplements, caudal and spinal anesthesia, and peripheral blockades.

The Compressed Baryonic Matter (CBM) experiment at the future Facility for Antiproton and Ion Research (FAIR) at GSI in Darmstadt will be a dedicated heavy-ion experiment exploring the QCD phase diagram in the region of moderate temperatures but very high baryon densities. The currently foreseen CBM detector setup, physics observables of interest, and first feasibility studies of their measurement will be presented.

Seit mehr als 100 Jahren wird die maschinelle Beat− mung zur Behandlung von Storungen der Atmung, der Atemmuskulatur und des pulmonalen Gasaustausches eingesetzt. Zu Beginn des 20. Jahrhunderts wurden Beatmungsgerate entwickelt, die aus einer den Kor− perstamm umfassenden, luftdichten Kammer bestan− den und durch Absenken des Kammerdrucks unter den Atmospharendruck eine Inspiration auslosten. Dieses Prinzip der negativen Druckbeatmung erlangte vor al− lem mit der Konstruktion einer fahrbaren Kammer, der 1Eisernen Lunge“, durch Drinker u. Shaw 1929 eine herausragende Bedeutung fur die Behandlung der pa− ralytischen Ateminsuffizienz. Auch wenn Magill bereits 1928 uber eine Ventilation per endotrachealer Intuba− tion wahrend operativer Eingriffe berichtete, so bekam diese Form der Beatmung, die positive Druckbeatmung, erst wahrend der Poliomyelitits−Epidemie 1952 in Ko− penhagen Aufwind. Wegen der Knappheit 1eiserner Lungen“ beatmeten bis zu 250 Studenten in Schichten mehr als 200 Patienten mit Beatmungsbeuteln.

Das Management des Atemwegs bei Neugeborenen, Sauglingen, Kleinkindern und Kindern kann aufgrund anatomischer und physiologischer Besonderheiten schwierig sein. Durch spezielle Lagerung wird dem im Vergleich zu Erwachsenen grosen Hinterkopf, dem kurzen Hals und dem Larynxhochstand Rechung getragen. Bei jeder Form von Beatmung ist die physiologisch hohe Atemfrequenz, die auf einem erhohten Sauerstoffbedarf und einer erhohten Kohlendioxidproduktion beruht, zu berucksichtigen. Zur Sicherung des Atemweges stehen verschiedene Hilfsmittel zur Verfugung. So kann die Maskenbeatmung durch den Einsatz eines Wendl-Tubus optimiert werden. Fur viele Indikationen kann zur Narkose die klassische Larynxmaske als schonendes Verfahren auch bei bestehendem Atemwegsinfekt empfohlen werden. Bei einigen Operationen und im Fall des nicht nuchternen Kindes ist die endotracheale Intubation notwendig. Hierbei muss auf die richtige Grose des Tubus und dessen Fixierungstiefe geachtet werden. Ist eine konventionelle Intubation aufgrund der Anamnese oder z. B. eines kraniofazialen Syndroms erschwert, sollte eine primar fiberoptische Intubation durchgefuhrt werden.

The investigation of nuclear matter at extreme conditions, that is, at high temperatures and/or at high baryon densities, is one of the most challenging fields of modern physics. Worldwide, major efforts are devoted to the exploration of the phase diagram of strongly interacting matter using high energy nucleus-nucleus collisions. While the experiments at the Relativistic Heavy Ion Collider (RHIC) at BNL and at the future Large Hadron Collider (LHC) at CERN focus on the study of high temperatures, the Compressed Baryonic Matter (CBM) experiment at the future FAIR accelerator will concentrate on the investigation of highest baryon densities at still moderate temperatures.

Aim: This study investigates angiotensin II and endothelin-1 mediated mechanisms involved in the haemodynamic, hormonal, and renal response towards acute hypotensive haemorrhage. Methods: Conscious dogs were pre-treated with angiotensin II type 1 (AT1) and/or endothelin-A (ETA) receptor blockers or not. Protocol 1: After a 60-min baseline period, 25% of the dog's blood was rapidly withdrawn. The blood was retransfused 60 min later and data recorded for another hour. Protocol 2: Likewise, but preceded by AT1 blockade with i.v. Losartan. Protocol 3: Likewise, but preceded by ETA blockade with i.v. ABT-627. Protocol 4: Likewise, but with combined AT1plus ETAblockade. Results: In controls, haemorrhage decreased mean arterial pressure (MAP) by approximately 25%, cardiac output by approximately 40%, and urine volume by approximately 60%, increased angiotensin II (3.1-fold), endothelin-1 (1.13-fold), vasopressin (116-fold), and adrenaline concentrations (3.2-fold). Glomerular filtration rate and noradrenaline concentrations remained unchanged. During AT1 blockade, the MAP decrease was exaggerated (−40%) and glomerular filtration rate fell. During ETA blockade, noradrenaline increased after haemorrhage instead of adrenaline, and the MAP recovery after retransfusion was blunted. The decrease in cardiac output was similar in all protocols. Conclusions: Angiotensin II is more important than endothelin-1 for the short-term regulation of MAP and glomerular filtration rate after haemorrhage, whereas endothelin-1 seems necessary for complete MAP recovery after retransfusion. After haemorrhage, endothelin-1 seems to facilitate adrenaline release and to blunt noradrenaline release. Haemorrhage-induced compensatory mechanisms maintain blood flow more effectively than blood pressure, as the decrease in cardiac output – but not MAP – was similar in all protocols.

Background The objective of this study was to determine whether endothelin-A receptor blockade (ETAB) impairs hemodynamic and hormonal regulation compared with controls and angiotensin II receptor blockade (AT1B) during hypotensive hemorrhage in dogs under isoflurane-nitrous oxide anesthesia. Methods Six dogs were studied in four protocols: (1) control experiments (controls); (2) ETA blockade using ABT-627 (ETAB); (3) AT1 blockade using losartan (AT1B); and (4) combined AT1B and ETAB (AT1B + ETAB). After a 30-min awake period, isoflurane-nitrous oxide anesthesia was established (1.3 minimum anesthetic concentration). After 60 min of anesthesia, 20 ml blood/kg body weight was withdrawn within 5 min, and the dogs were observed for another hour. Thereafter, the blood was retransfused, and the dogs were observed for a final hour. Results Anesthesia: Cardiac output decreased in all protocols, whereas mean arterial pressure decreased more in AT1B and AT1B + ETAB than in controls and ETAB. Hemorrhage: After 60 min, cardiac output had decreased less in controls than in all other protocols. Mean arterial pressure decreased more during ETAB than in controls, but most severely during AT1B and AT1B + ETAB. Angiotensin II increased further only in controls and ETAB, whereas vasopressin and catecholamines increased similarly in all protocols. Retransfusion: Mean arterial pressure remained below controls in all protocols but was lowest when the AT1 receptor was blocked. Cardiac output fully recovered in all but the ETAB protocol. Conclusions ETAB impairs long-term hemodynamic regulation after hemorrhage and retransfusion during anesthesia despite an activation of vasoconstrictive hormones. This suggests that endothelins have a role in long-term cardiovascular regulation. AT1B impairs both short- and long-term blood pressure regulation during anesthesia and after hemorrhage.

The pharmacokinetics of opioids are impaired in patients with liver and renal failure. Fentanyl, sufentanil, and alfentanil are metabolized in the liver. The extrahepatic metabolism by renal enzymes is gaining more importance in patients with severe liver disease. Pharmacokinetic effects of single doses of fentanyl and sufentanil are not affected in liver and renal failure; however, continuous infusion of fentanyl may result in accumulation and prolonged opioid effects. Plasma clearance and elimination of alfentanil are reduced in patients with liver failure and its clinical use can therefore not be recommended. A reduction in alfentanil dosing is not necessary in patients with renal failure. Remifentanil is the opioid of choice in patients with liver and renal failure. The clearance of morphine is reduced in liver failure. In renal failure an accumulation of morphine metabolites has been demonstrated, and thus, application of morphine is not recommended in patients with liver and renal failure. A reduction in piritramide dosing is necessary in patients with liver failure.

Background: This study investigates whether long-term treatment with an angiotensin converting enzyme inhibitor (ACEI) impairs the hemodynamic regulation during the early phase of spinal anaesthesia. Methods: Forty-two patients undergoing minor surgery were studied. Twenty-one patients were long-term treated (ACEI group), while the other patients served as controls (nonACEI group). All patients received a balanced electrolyte solution(6 ml kg−1) 20 min before spinal anaesthesia. Results: Mean arterial blood pressure decreased 19% in both groups within 20 min after spinal anaesthesia. Heart rate did not change in either group. Plasma renin concentration increased from 7.3 ± 2.1 to 12.8 ± 4 pg ml−1 during spinal anaesthesia in nonACEI patients (P

This study compares the haemodynamic and hormonal responses during haemorrhage of conscious dogs pre-treated with an endothelin-A (ET-A) receptor inhibitor. The dogs were studied in two different randomized groups: the control group and a group that was given the ET-A receptor antagonist ABT-627 (as a bolus of 1 mg x kg of body weight(-1) followed by 0.01 mg x kg body weight(-1) x min(-1) intravenously). The time-course was the same for both groups: after a 1 h baseline period (pre-haemorrhage), blood (25 ml x kg of body weight(-1)) was withdrawn within 5 min. Haemodynamics were continuously recorded and hormone levels measured after 1 h (post-haemorrhage). Thereafter, the blood withdrawn was retransfused within 5 min and haemodynamics again observed for 1 h (post-retransfusion). In ABT-627-treated dogs, the decrease in mean arterial pressure from 87+/-3 to 64+/-3 mmHg (P

Acute hypoxia causes hyperventilation and respiratory alkalosis, often combined with increased diuresis and sodium, potassium, and bicarbonate excretion. With a low sodium intake, the excretion of the anion bicarbonate may be limited by the lower excretion rate of the cation sodium through activated sodium-retaining mechanisms. This study investigates whether the short-term renal compensation of hypoxia-induced respiratory alkalosis is impaired by a low sodium intake. Nine conscious, tracheotomized dogs were studied twice either on a low-sodium (LS = 0.5 mmol sodium · kg body wt−1· day−1) or high-sodium (HS = 7.5 mmol sodium · kg body wt−1· day−1) diet. The dogs breathed spontaneously via a ventilator circuit during the experiments: first hour, normoxia (inspiratory oxygen fraction = 0.21); second to fourth hour, hypoxia (inspiratory oxygen fraction = 0.1). During hypoxia (arterial Po234.4 ± 2.1 Torr), plasma pH increased from 7.37 ± 0.01 to 7.48 ± 0.01 ( P < 0.05) because of hyperventilation (arterial Pco225.6 ± 2.4 Torr). Urinary pH and urinary bicarbonate excretion increased irrespective of the sodium intake. Sodium excretion increased more during HS than during LS, whereas the increase in potassium excretion was comparable in both groups. Thus the quick onset of bicarbonate excretion within the first hour of hypoxia-induced respiratory alkalosis was not impaired by a low sodium intake. The increased sodium excretion during hypoxia seems to be combined with a decrease in plasma aldosterone and angiotensin II in LS as well as in HS dogs. Other factors, e.g., increased mean arterial blood pressure, minute ventilation, and renal blood flow, may have contributed.

Postoperative nausea and vomiting (PONV) has a high incidence in children and requires prophylactic and therapeutic strategies.PONV can be reduced by the avoidance of nitrous oxide, volatile anesthetics, and the reduction of postoperative opioids. The use of dexamethasone, 5-HT3 antagonists, or droperidol alone is potent, but combinations are even more effective to reduce PONV. Droperidol has a Food and Drug Administration warning. Hence, dexamethasone and 5-HT3 antagonists should be preferred as prophylactic drugs. It is further reasonable to adapt PONV prophylaxis to different risk levels. Prolonged surgery time, inpatients, types of surgery (e.g. strabismus and ear-nose-throat surgery), and patients with PONV in history should be treated as high risk, whereas short procedures and outpatients are to be treated as low risk.Concluding from the existing guidelines and data on the handling of PONV in children at least 3 years, the following recommendations are given: outpatients undergoing small procedures should receive a single prophylaxis, outpatients at high risk a double prophylaxis, inpatients with surgery time of more than 30 min and use of postoperative opioids should get double prophylaxis, and inpatients receiving a high-risk surgical procedure or with other risk factors a triple prophylaxis (two drugs and total intravenous anesthesia). Dimenhydrinate can be used as a second choice, whereas droperidol and metoclopramide can only be recommended as rescue therapy.

This study investigated whether adenosine mediates the decrease in plasma renin activity (PRA) during acute hypoxia. Eight chronically tracheotomized, conscious beagle dogs were kept under standardized environmental conditions and received a low-sodium diet (0.5 mmol · kg body wt−1 · day−1). During the experiments, the dogs were breathing spontaneously via a ventilator circuit: first hour, normoxia (21% inspiratory concentration of O2); second and third hours, hypoxia (10% inspiratory concentration of O2). Each of the eight dogs was studied twice in randomized order in control and theophylline experiments. In theophylline experiments, theophylline, an A1-receptor antagonist, was infused intravenously during hypoxia (loading dose: 3 mg/kg within 30 min, maintenance: 0.5 mg · kg−1 · h−1). In theophylline experiments, PRA (5.9 ± 0.8 ng ANG I · ml−1 · h−1) and ANG II plasma concentration (15.9 ± 2.3 pg/ml) did not decrease during hypoxia, whereas plasma aldosterone concentration decreased from 277 ± 63 to 132 ± 23 pg/ml ( P < 0.05). In control experiments, PRA decreased from 6.8 ± 0.8 during normoxia to 3.0 ± 0.5 ng ANG I · ml−1 · h−1 during hypoxia, ANG II decreased from 13.3 ± 1.9 to 7.3 ± 1.9 pg/ml, and plasma aldosterone concentration decreased from 316 ± 50 to 70 ± 13 pg/ml ( P < 0.05). Thus infusion of the adenosine receptor antagonist theophylline inhibited the suppression of the renin-angiotensin system during acute hypoxia. The decrease in aldosterone occurred independently and is apparently directly related to hypoxia. In conclusion, it is likely that adenosine mediates the decrease in PRA during acute hypoxia in conscious dogs.

Part 0: General Introduction.- Part I: Bulk Properties of Strongly Interacting Matter.- Part II: In-Medium Excitations.- Part III Collision Dynamics.- Part IV: Observables and Predictions.- Part V The CBM Experiment.- Glossary.- References.

The incidence of overweight and obesity in children and adolescents who need an anesthesia is increasing. These children have a higher risk for perioperative complications. The review discusses definition and causes of obesity in children, gives information about relevant pathophysiological changes, and focuses anesthesiological management and complications.

The increase in intra-abdominal pressure may be followed by a renal, gut, respiratory and cardial dysfunction and an increase in intra-cranial pressure. The review focuses risk factors and pathophysiological consequences of intra-abdominal hypertension and of abdominal compartment syndrome. Patients with intra-abdominal hypertension and abdominal compartment syndrome are critical ill and need special anesthesiological care due to risk of pulmonary aspiration, hemodynamic disturbances and difficult mechanical ventilation.

The noble gas xenon seems to have minimal cardiovascular side-effects and so may be an ideal anaesthetic agent when investigating cardiovascular physiology. In comparison with standard modern anaesthetics, we investigated the haemodynamic and hormonal effects of xenon in Beagle dogs. After a 30 min baseline period, anaesthesia was induced with propofol and maintained with either (1) 1.2% isoflurane/70% nitrous oxide (N2O), (2) 0.8% isoflurane/0.5 µg/kg/min remifentanil or (3) 63% xenon/0.5 µg/kg/min remifentanil ( n = 6 per group). Haemodynamics were recorded and blood samples taken before and 60 min after induction. Mean arterial blood pressure (MAP) was higher in conscious dogs than during isoflurane/N2O (86 ± 2 vs. 65 ± 2 mmHg, mean ± SEM) and isoflurane/remifentanil anaesthesia (95 ± 2 vs. 67 ± 3 mmHg), whereas MAP did not decrease significantly in response to xenon/remifentanil anaesthesia (96 ± 4 vs. 85 ± 6 mmHg). Bradycardia was present during isoflurane/remifentanil (54 ± 2/min) and xenon/remifentanil (40 ± 3/min), but not during isoflurane/N2O anaesthesia (98 ± 3/min, P < 0.05). Xenon/remifentanil anaesthesia induced the highest reduction in cardiac output (CO) (–61%), and the highest increase in systemic vascular resistance (+120%) among all treatment groups ( P < 0.05). A simultaneous increase in endogenous adrenaline and noradrenaline concentrations could only be observed in the xenon/remifentanil group, whereas angiotensin II and vasopressin concentrations increased in all groups. In conclusion, xenon/remifentanil anaesthesia maintains MAP but reduces heart rate and CO and is associated with a considerable stimulation of vasopressor hormones in Beagle dogs. Therefore, xenon/remifentanil exerts a new quality of adverse haemodynamic effects different from volatile anaesthetics and may not perform better during studies of cardiovascular physiology.

The effects of endothelin receptor subtype A (ETA) blockade on hemodynamics and hormonal adaptation during hemorrhage were studied in xenon/remifentanil-anesthetized dogs (n=6) pretreated with an angiotensin II type 1 (AT1)-receptor blocker.after a baseline awake period, anesthesia was induced in the dogs with propofol and maintained with xenon/remifentanil (baseline anesthesia). Sixty minutes later, 20 mL x kg(-1) of blood was withdrawn within 5 min and the dogs observed for another hour (hemorrhage). AT1 group followed the same protocol as controls except the AT1-receptor blocker losartan (i.v. 100 microg x kg(-1) x min(-1)) was started at the beginning of the experiment. AT1+ETA group was the same as AT1 group but with the addition of the ETA-receptor blocker atrasentan (i.v. 1 mg x kg(-1), then 0.01 mg x kg(-1) x min(-1)). In controls, mean arterial pressure (MAP) remained unchanged during baseline anesthesia, whereas systemic vascular resistance (SVR) increased from 3282+/-281 to 7321+/-803 dyn.s.cm-5, heart rate (HR) decreased from 86+/-4 to 40+/-3 beats x min(-1), and cardiac output (CO) decreased from 2.3+/-0.2 to 0.9+/-0.1 L x min(-1) (p0.05), with no further changes after hemorrhage. In AT1-inhibited dogs, MAP (71+/-6 mm Hg) and SVR (5939+/-611 dyn x s x cm(-5)) were lower during baseline anesthesia and after hemorrhage, but greater than those in AT1+ETA (66+/-7 mm Hg, 5034+/-658 dyn x s x cm(-5)) (p0.05). HR and CO were not different between groups. Plasma concentration of vasopressin was highest with AT1+ETA inhibition after hemorrhage. Combined AT1+ETA-receptor blockade impaired vasoconstriction more than did AT1-receptor blockade alone, both during baseline xenon anesthesia and after hemorrhage. Even a large increase in vasoconstrictor hormones could not prevent the decrease in blood pressure and the smaller increase in SVR. Thus, endothelin is an important vasoconstrictor during hemorrhage, and both endothelin and angiotensin II are essential hormones for cardiovascular stabilization after hemorrhage.