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Luisa Trübenbacher,1 Nicole Lindenberg,1 Bernhard M Graf,1 Markus Backmund,2 Wilhelm Unglaub,3 Christoph L Lassen1 1Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Regensburg, Regensburg, 93053, Germany; 2“Praxiszentrum im Tal”, Tal 9, 80331, Ludwig-Maximilians-University, Munich, Germany; 3“medbo” District Hospital, Universitätsstraße 84, 93053, University of Regensburg, Regensburg, GermanyCorrespondence: Luisa Trübenbacher, Department for Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany, Tel +49 941 944-7810, Fax +49 941 944-7832, Email luisa.truebenbacher@stud.uni-regensburg.deBackground: Opioid induced hyperalgesia (OIH) describes a state of altered pain sensation due to opioid exposure. It often occurs among persons with opioid use disorder receiving substitution therapy.Methods: The purpose of this study was to find out, whether OIH diagnosis could be facilitated by an objective pain indicating marker: the Nociceptive Flexion Reflex (NFR). Forty persons with opioid use disorder, 20 of them maintained on methadone and 20 treated with buprenorphine, as well as a control group of 20 opioid-free subjects, were examined. It was aimed to find out whether and in which way these opioid agonists alter reflex threshold (NFR-T). A cold-pressor test was performed to investigate the prevalence of OIH. Furthermore, electrical stimulation and electromyography analyzation were used for NFR-T measurement. Subjective pain ratings were evaluated with a numeric rating scale.Results: Significantly increased sensitivity to cold pressor pain was found in both maintenance groups when compared to their opioid-free counterparts (p < 0.001). Neither methadone nor buprenorphine showed any effect on NFR-T. This might be explained by the reflex approaching at the wrong location in the central nervous system. Consequently, NFR-T is not a suitable marker for diagnosing OIH.Conclusion: Although methadone and buprenorphine have been proven to cause OIH, no effect on NFR-T was observed. A statistically significant effect could have been observed with a larger number of participants. Further research, with special focus on patients’ adjuvant medication, should be conducted in the future, to facilitate diagnosis of OIH and provide appropriate pain management for maintenance patients.Keywords: hyperalgesia, analgesics, opioid, substance-related disorders, methadone, buprenorphine

The necessity of limiting resource in healthcare systems is becoming increasingly more evident. The population has requirements especially in the field of healthcare which are principally unlimited. However, there are only limited financial resources which can be used to satisfy the wishes of the population. For this reason rationing models are being discussed increasingly more often. One example of these models is called age rationing which means that defined services are only offered to patients up to a particular age. The aim of this article is to discuss the model of age rationing in the context of an optimized use of resources in the healthcare system. [ABSTRACT FROM AUTHOR]

A case of pulmonary edema after the administration of naloxone for laparoscopic splenectomy is reported. Previous reports of naloxone-induced pulmonary edema are listed and reviewed. The clinical course is compared to other forms of non-cardiogenic pulmonary edema. Uncertainty remains about the underlying pathophysiological process and the true impact of naloxone on the development of pulmonary edema. [ABSTRACT FROM AUTHOR]

Intensive care unit-acquired weakness (ICUAW) is a severe complication in critically ill patients which has been increasingly recognized over the last two decades. By definition ICUAW is caused by distinct neuromuscular disorders, namely critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Both CIP and CIM can affect limb and respiratory muscles and thus complicate weaning from a ventilator, increase the length of stay in the intensive care unit and delay mobilization and physical rehabilitation. It is controversially discussed whether CIP and CIM are distinct entities or whether they just represent different organ manifestations with common pathomechanisms. These basic pathomechanisms, however, are complex and still not completely understood but metabolic, inflammatory and bioenergetic alterations seem to play a crucial role. In this respect several risk factors have recently been revealed: in addition to the administration of glucocorticoids and non-depolarizing muscle relaxants, sepsis and multi-organ failure per se as well as elevated levels of blood glucose and muscular immobilization have been shown to have a profound impact on the occurrence of CIP and CIM. For the diagnosis, careful physical and neurological examinations, electrophysiological testing and in rare cases nerve and muscle biopsies are recommended. Nevertheless, it appears to be difficult to clearly distinguish between CIM and CIP in a clinical setting. At present no specific therapy for these neuromuscular disorders has been established but recent data suggest that in addition to avoidance of risk factors early active mobilization of critically ill patients may be beneficial. [ABSTRACT FROM AUTHOR]

The use of enteral feeding tubes is an important part of early enteral feeding in intensive care medicine. In other faculties with non-critically ill patients, such as (oncologic) surgery, neurology, paediatrics or even in palliative care medicine feeding tubes are used under various circumstances as a temporary or definite solution. The advantage of enteral feeding tubes is the almost physiologic administration of nutrition, liquids and medication. Enteral nutrition is thought to be associated with a reduced infection rate, increased mucosal function, improved immunologic function, reduced length of hospital stay and reduced costs. However, the insertion and use of feeding tubes is potentially dangerous and may be associated with life-threatening complications (bleeding, perforation, peritonitis, etc.). Therefore, the following article will give a summary of the different types of enteral feeding tubes and their range of application. Additionally, a critical look on indication and contraindication is given as well as how to insert an enteral feeding tube. [ABSTRACT FROM AUTHOR]

Background: At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients.Methods: For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources.Results: As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment.Conclusions: Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary. [ABSTRACT FROM AUTHOR]

The use of extracorporeal membrane oxygenation (ECMO) was established in Germany 25 years ago in specialized centers as an approach for patients suffering from severe life-threatening lung failure. Apart from such indications the inclusion of ECMO as a planned intervention for safety purposes in the postoperative weaning from mechanical ventilation in a 22-year-old woman is described. Following a complex tracheal reconstruction due to oesophageal-tracheal fistula formation, conventional weaning procedures would have been accompanied by a very high risk as extubation failure might have caused an airway disaster. After elective use of veno-venous ECMO the young patient was extubated without risk and lung function was stabilized safely. Extracorporeal lung assist can be indicated apart from rescue management in elective situations for prevention of an airway catastrophe after careful calculation of the harm/benefit ratio. [ABSTRACT FROM AUTHOR]

Background: Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.Methods: During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.Results: Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.Conclusions: Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely. [ABSTRACT FROM AUTHOR]

Modern anesthesia is handling an increasing number of patients with neurological diseases who require narcosis. Regional anesthesia techniques offer qualities which might be advantageous for this group particularly for childbirth. The number of pregnant women with neurological diseases has increased significantly in the recent years due to improved diagnostics and therapy. A more careful approach to regional anesthesia in patients with neurological diseases is necessary as the drugs themselves possess neurotoxic effects and the procedure might worsen the underlying neurological diseases. Additionally, performing regional anesthesia might be more complicated and the resulting blockade might be different from the expected neuronal block. Published data concerning regional anesthesia in this patient group are limited and mainly restricted to case reports. In this review general considerations regarding regional anesthesia, techniques, drugs and methods in these patient groups will be discussed. In the second part the practical approach to regional anesthesia for some of the most important neurological diseases is highlighted. [ABSTRACT FROM AUTHOR]

Acute renal failure (ARF) is clinically defined as an abrupt, but in principle reversible deterioration of glomerular and tubular function. Regarding pathophysiology, ARF is caused by ischemic renal conditions and toxic mediators. Sepsis is the most common cause of ARF in the intensive care unit and ARF is an independent risk factor for lethality of septic patients. Interventions to protect the kidneys against ARF include preliminary optimization of renal perfusion by volume load with cristalloid solutions and the administration of vasopressors. Daily maximum permissible dosages for colloids should not be exceeded and hyperoncotic colloid solutions should be generally avoided. Dopamine in "renal dosage" is nowadays obsolete. Loop diuretics produce diuresis and can be beneficial to extrarenal organs by improving fluid homeostasis, however diuretics do not improve kidney function and outcome. Therefore, diuretics are not indicated for patients with imminent or existing ARF. Septic patients with ARF can be treated by intermittent and continuous forms of renal replacement therapy, whereas continuous convective and intermittent diffusive methods are equivalent when utilizing an ultrafiltration rate > or =20 ml/h*kg body weight or a therapeutic interval > or =3 times/week. [ABSTRACT FROM AUTHOR]

Background: In the medical literature the Lazarus phenomenon is defined as the spontaneous return of circulation (SROC) after cessation of cardio-pulmonary resuscitation. Based on published literature recommendations concerning the treatment of patients after cessation of resuscitation and reasons for the Lazarus phenomenon are discussed.Methods: A literature search in Medline, PubMed, Embase, Google Scholar and Google from 1982 to 2009 was carried out for the terms "Lazarus phenomenon", "cessation of cardiopulmonary resuscitation and return of spontaneous circulation (ROSC)", "spontaneous return of circulation (SROC)", "resuscitation and spontaneous defibrillation", "spontaneous recovery and cardiopulmonary resuscitation". Related secondary literature which was cited in the relevant articles was included as well as publications found in our personal literature base.Results: More than 10,000 articles and comments could be recovered and of these 45 were considered to be medically relevant articles (letters to the Editor, abstracts, case reports and literature reviews).Conclusions: In the relevant medical literature, the Lazarus phenomenon is a rare occurrence. It seems to be a phenomenon which has often been described in non-medical literature but not published in medical literature. The pathophysiological mechanisms are poorly understood. In the literature several mechanisms are discussed which could be important for this phenomenon, e.g. autopositive end-expiratory pressure, hyperventilation and alkalosis, hyperkalemia, delayed action of drugs and unobserved minimal vital signs. In the literature it is recommended that patients should be passively monitored for at least 10 min after cessation of resuscitation. However, more scientific experimental investigations seem to be necessary to gain a better understanding of this phenomenon. [ABSTRACT FROM AUTHOR]

Background: In Germany, specialized out-patient palliative care systems (SPCS) are still structurally and organizationally under construction. Palliative care patients need an easy access to a qualified SPCS. The purpose of the present investigation was to show the nationwide distribution of all SPCS teams in comparison to the distribution of emergency medical systems. Possibilities for an effective structure of palliative medical care systems will be discussed in order to optimize patient care..Methods: All SPCS teams in Germany (according to the Guide to hospices and palliative medicine of the German Association for Palliative Care 2008/2009) were documented. A cartographic representation of the structural distribution of palliative care systems was made taking a catchment area diameter of 50 km for each SPCS team and an accessibility diameter of 20 km for every palliative ward into account. These data were compared with the nationwide distribution of emergency institutions.Results: In Germany 25 SPCS teams and 198 palliative wards could be identified. In contrast there are 1,109 emergency physician locations (1,051 ground based, 58 air based). The nationwide distribution of the existing SPCS teams does not at present give exhaustive coverage in comparison to emergency medical structures. No structure which might potentially result in an exhaustive implementation of SPCS teams and palliative stations is recognizable in the analysis or distribution.Conclusions: The coverage of SPCS and in-hospital palliative care is still a theoretical construct in many regions of Germany. The number of existing SPCS teams and in-patient palliative institutions is insufficient to guarantee an exhaustive coverage of patient care as in emergency medical services. In order to achieve a higher quality of results the quality of the structure and processes must first be ensured. The distribution of palliative care should be centrally coordinated along the same lines as the emergency institutions in order to achieve a need-oriented exhaustive coverage. A surplus of care in some regions at the expense of an undersupply in other regions must be avoided. In the next step a further development and adaption of existing structures to the requirements would be a logical approach. [ABSTRACT FROM AUTHOR]

Background: The number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.Methods: In a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows--group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care.Results: During the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01).Conclusions: In Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients. [ABSTRACT FROM AUTHOR]

Background: The treatment of out-of-hospital palliative emergency care situations during cardiac arrest is a special situation. The prehospital emergency physician (EP) and the paramedic must be informed about the medical, legal, and ethical specifics of these situations, but this knowledge is not integrated within emergency medical curricula at all. We present a case study to discuss such legal and ethical specifics.Methods: We retrospectively analysed six emergency cases with palliative care patients in the final stages of their illnesses. On the basis of these case studies, we present six different emergency cases with different regulatory frameworks for each EP and paramedic. In accordance with the Declaration of Helsinki, data were collected pseudonymously.Results: The six case studies show therapeutic concepts concerning the emergency medical care of palliative care patients during cardiac arrest. The differences are apparent in the treatment given by EPs and by paramedics (such as whether to start or stop resuscitation). EPs and paramedics differ in their therapeutic approach to these specific situations (e.g. paramedics more often start resuscitation during cardiac arrest even though patients would refuse this according to their advance directives). These differences may be important for the patient and his or her caregivers.Conclusions: Every EP and paramedic may be involved in the care of palliative care patients who are at the end of their lives. EPs and paramedics do not always adapt their treatment to the will or supposed will of the patient (especially in accordance with the new German law concerning advance directives). The reasons for this usually concern legal uncertainties. Therefore, EPs and paramedics should know that different legal meanings could be important in emergency medical care therapy of palliative care patients. A written "do not resuscitate" order as an advance directive must be evaluated as a desired therapeutic limitation. [ABSTRACT FROM AUTHOR]

Safe and effective cranial analgesia can be achieved by blocking the sensitive nerves of that region. These include the supraorbital nerve, the supratrochlear nerve, the zygomaticotemporal nerve, the auriculotemporal nerve and the greater and lesser occipital nerves which are accessible at typical and most proximal points. Preferably long acting local anesthetics such as ropivacaine 0.75% or levobupivacaine 0.5% are used supplemented with 5 microg/ml epinephrine to reduce systemic resorption and to elongate the duration. Scalp blocks are useful for intraoperative neurologic testing of the patient during awake craniotomy or for supplementation of general anesthesia for other forms of craniotomy. Other applications are minimally invasive and stereotactic neurosurgery including deep brain stimulation, photodynamic therapy of actinic ceratosis, cranial plastic surgery and pain therapy. [ABSTRACT FROM AUTHOR]

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement. [ABSTRACT FROM AUTHOR]

Background: The Laryngeal Mask Airway Supreme (LMA-S) is a new disposable airway device that combines features of the LMA ProSeal (PLMA, gastric access) and LMA Fastrach (curved shaft to ease insertion) and has been available since April 2007.Methods: In a prospective study, 10 final year medical students or first year anesthesia residents, all with limited experience in LMA anesthesia, were requested to manage the airway of anesthetized female patients with the LMA-S size 4, who seemed normal on routine airway examination. Data collection included the success rates and duration for insertion, oropharyngeal leak pressures (OLP), fiber optic position and airway morbidity.Results: A total of 30 patients were enrolled in the study. Insertion of the LMA-S was possible in 27 (90%) patients at the first attempt and in 3 (10%) at the second attempt. Ventilation was established in 18.3 s (range 10-30 s, standard deviation +/-4.2 s). Insertion of a gastric tube was possible in all patients at the first attempt. Mean OLP at the level of 60 cmH2O cuff pressure was 29.1 cmH2O (range 21-35 cmH2O, standard deviation +/-4.8 cmH2O). Laryngeal fit evaluated by fiber optic control was rated as optimal in all patients both immediately after insertion of the LMA-S and after end of surgery. Three patients (10%) complained of mild sore throat. No patient reported dysphagia or dysphonia.Conclusion: Insertion of the LMA-S was successful and possible in all patients in < or = 30 s with an optimal laryngeal fit, high OLPs and low airway morbidity. The LMA-S seems to be a device suitable for use in routine anesthesia and which can be safely used by medical personnel with limited clinical experience. [ABSTRACT FROM AUTHOR]

Objective: In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure.Methods: An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire.Results: During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation.Conclusion: The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario. [ABSTRACT FROM AUTHOR]

A paediatric emergency case with a rescue helicopter, which was reported as unexpected cardiac arrest of a 4-year-old child will be described. Based on this case, the symptoms and therapy of meningococcal sepsis and Waterhouse-Friderichsen-Syndrome under emergency conditions will be discussed as well as aspects of post-exposure prophylaxis. [ABSTRACT FROM AUTHOR]

Severe clinical incidents occur in up to 10% of all non-intensive care unit (ICU) patients, which have an estimated mortality of 5-8%. As in the prehospital setting, early clinical warning signs can be identified in the majority of cases. Studies suggest that introduction of an in-hospital medical emergency team (MET) which responds to objective criteria of physiological deterioration, may effectively reduce the incidence of in-hospital cardiac arrests as well as unanticipated or readmissions to the ICU. According to this concept, METs would evaluate and treat non-ICU patients at risk at an early stage before a potentially fatal deterioration of cardiorespiratory parameters occurs. This article reviews available data on preventive in-hospital intensive care medicine and reflects on the circumstances for an implementation of METs in Germany, Austria and Switzerland. [ABSTRACT FROM AUTHOR]