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The bedside Exhaled Drug MONitor – EDMON measures exhaled propofol in ppbv every minute based on multi-capillary column – ion mobility spectrometry (MCC-IMS). The MCC pre-separates gas samples, thereby reducing the influence of the high humidity in human breath. However, preliminary analyses identified substantial measurement deviations between dry and humid calibration standards. We therefore performed an analytical validation of the EDMON to evaluate the influence of humidity on measurement performance. A calibration gas generator was used to generate gaseous propofol standards measured by an EDMON device to assess linearity, precision, carry-over, resolution, and the influence of different levels of humidity at 100% and 1.7% (without additional) relative humidity (reference temperature: 37°C). EDMON measurements were roughly half the actual concentration without additional humidity and roughly halved again at 100% relative humidity. Standard concentrations and EDMON values correlated linearly at 100% relative humidity (R²=0.97). The measured values were stable over 100min with a variance ≤ 10% in over 96% of the measurements. Carry-over effects were low with 5% at 100% relative humidity after 5min of equilibration. EDMON measurement resolution at 100% relative humidity was 0.4 and 0.6 ppbv for standard concentrations of 3 ppbv and 41 ppbv. The influence of humidity on measurement performance was best described by a second-order polynomial function (R²≥0.99) with influence reaching a maximum at about 70% relative humidity. We conclude that EDMON measurements are strongly influenced by humidity and should therefore be corrected for sample humidity to obtain accurate estimates of exhaled propofol concentrations.

We investigated the conceptualization and impact of adverse childhood experiences (ACEs) in a sample of 231 children ages 3-5 living in poverty and experiencing homelessness, focusing specifically on caregiver well-being and housing instability. Data was collected using the Neurodevelopmental Ecological Screening Tool (NEST), which screens for developmental risk and resilience across three domains (neurodevelopmental, caregiver, and environment). We used structural equation modelling (SEM) to test the association between domains and ACE scores and assessed the impact on neurodevelopmental constructs. Fifty-five percent of the sample had high ACE scores ( 3), which were associated with lower attention, social skills, and emotional regulation. ACEs were strongly associated with 0.17 standard deviation units of higher levels of caregiver distress (

The growth of school-based initiatives incorporating multitiered systems of support (MTSS) for social, emotional, and behavioral domains has fueled interest in behavioral assessment. These assessments are foundational to determining risk for behavioral difficulties, yet research to date has been limited with regard to when and how often to administer them. The present study evaluated these questions within the framework of behavioral stability and examined the extent to which behavior is stable when measured by two school-based behavioral assessments: the Direct Behavior Rating-Single-Item Scales (DBR-SIS), and the Behavioral and Emotional Screening System (BESS). Participants included 451 students rated three times per year across 4 years, with the primary teacher from each year providing the within-year ratings. Latent variable models were employed to measure the constructs underlying the observed assessment scores. Models demonstrated that the DBR-SIS best captured changes within the year, whereas the BESS scores remained stable across time points within a year. Across years, scores from both assessments captured changes. The unique contributions of each assessment in the data-based decision-making process are discussed, and recommendations are given for their combined use within and across school years. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Neurodevelopmental Ecological Screening Tool (NEST) is a new instrument to screen children for developmental challenges. This article describes the validation of the NEST neurodevelopmental domain. Data were collected from a nationwide purposely restricted sample of caregivers of children aged 3–5 years ( n = 231) living in poverty and experiencing homelessness. We used Rasch-based Rating Scale Models to select items with good fit. Cronbach’s alpha was used to measure the internal consistency validity of the entire neurodevelopmental domain. Construct validity and dimensional structure were obtained using confirmatory factor analysis. Interclass correlations were used to measure the test–retest reliability of the subdomains. Neurodevelopmental Ecological Screening Tool scores were compared to results on clinician-administered gold standard measures for a subsample ( n = 48). The neurodevelopmental domain score represents a single overarching risk construct with some variance attributable to distinct developmental constructs and validly and reliably identifies a child’s level of developmental risk.

Young children from impoverished backgrounds experience high levels of family and environmental stress, adversely impacting developmental functioning. Early identification provides a pathway to solutions, but many children are never assessed. In addition, the child-serving workforce lacks resources and expertise to use traditional measures. Furthermore, existing measures do not account for the substantial influence of a child’s ecology. To bridge these gaps, we developed the Neurodevelopmental Ecological Screening Tool (NEST) and conducted a pilot study (n=60) to test its feasibility for use with caregivers of children ages 3-5 in low-resource settings. We developed an item pool across three domains (child, caregiver, environment), vetted it with experts, and conducted cognitive interviewing with parents (n=15) and case managers (n-10). Simultaneously, we built an online, user-friendly delivery platform. We used a one parameter Item Response Model and a Rasch-based Rating Scale Model (RSM) and fit confirmatory factor analytic (CFA) models to test for unidimensional and construct validity. The results support the feasibility of screening children from low SES populations within low-resource settings using an ecological perspective and supports the work of child-serving paraprofessionals in identifying and addressing risks in the lives of young children.

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.

The bedside Exhaled Drug MONitor - EDMON measures exhaled propofol in ppb

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.

Background Analysis of exhaled air is a risk-free option for bedside diagnostics. Modern breath analysis can detect very low concentrations of volatile components. Current research focuses on drug monitoring and diagnosis of various diseases. Objectives Presentation and discussion of current breath research relevant to intensive care medicine. Materials and methods The literature in PubMed was searched using the following terms: "breath analysis", "volatile organic compounds", "critically ill" combined with "drug monitoring", "propofol", "heart failure", "pneumonia", "ARDS", "renal failure", "liver failure", "sepsis" or "hemorrhage". Results Intravenously administered propofol can now be measured reliably in exhaled air. Functional impairments of the heart, lungs, kidneys and liver show characteristic influences on the exhaled air, which could serve as a new diagnostic tool in the future. Animal experiments already show promising results to detect sepsis, hemorrhage and ventilator-induced lung injury. Conclusions In the future, modern breath analysis could enable non-invasive drug monitoring and diagnostics of medical conditions relevant to intensive care medicine.

Purpose To investigate whether a training program on breast ultrasound skills including core-needle biopsies to undergraduate students can improve medical knowledge and learning satisfaction. Methods Medical students attending mandatory classes at the Medical School of the University of Saarland received a supplemental theoretical and hands-on training program on ultrasound (US) breast screening and on US-guided core-needle biopsy using an agar–agar phantom. Experienced breast specialists and ultrasound examiners served as trainers applying Peyton’s 4-step training approach. The students’ theoretical knowledge and hands-on skills were tested before and after the training program, using a multiple-choice questionnaire (MCQ), the Objective Structured Clinical Examination (OSCE) and a student curriculum evaluation. Results The MCQ results showed a significant increase of the student’s theoretical knowledge (50.2–75.2%, p Conclusion Undergraduate student’s medical education can be enhanced by teaching breast US skills.

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.Rumpfblockaden zur Regionalanästhesie haben mit Einführung der Sonographie eine neue Bedeutung erfahren. Durch Umgehung von zu meidenden Begleitstrukturen hilft der Ultraschall, Komplikationen zu vermeiden. Zusätzlich sind komplexe Punktionen möglich, die allein durch Landmarken zu risikoreich wären. Neben der gezielten Blockade einzelner Nervenstrukturen haben sich auch interfasziale bzw. Kompartimentblockaden etabliert, bei denen die Darstellung einzelner Nerven oder Plexusstrukturen nicht von Bedeutung ist. Die vorliegende Übersichtsarbeit beschreibt publizierte und klinisch etablierte Punktionstechniken bezüglich ihrer Indikationen und Durchführung. Es wird erläutert, welchen Stellenwert sie in Bezug auf Wirkungsprofil und klinisch-wissenschaftliche Evidenz haben. Weiterhin erläutern die Autoren mögliche Komplikationen, Risiken und Lokalanästhetikadosierungen.

This article reports the case of a 29-year-old female Jehovah's Witness with severe anemia after intrauterine fetal death in the 25th week of gestation, complicated by vaginal bleeding, acute renal failure and hemolysis. Due to her religious beliefs the patient categorically refused blood transfusions. Despite adhering to the recommendations for patient blood management, the hemoglobin (Hb) level gradually decreased to 1.9 g/dl on day 10, when she fainted and had to be sedated and invasively ventilated. Inhalative isoflurane was chosen for sedation because of its potential organ-protective effects and because it provides deep sedation with reduced oxygen requirements, while enabling rapid neurological examination during the sedation windows as well as regular and calm spontaneous breathing. Posthypoxic encephalopathy was demonstrated clinically and electroencephalographically by seizure activity during the sedation windows. Anticonvulsive treatment was started. At a hemoglobin of 1.8 g/dl, she received 2 units of polymerized bovine hemoglobin (Hemopure®, Hemoglogin Oxygen Therapeutics LLC, Souderton, PA, USA), repeated several times on subsequent days because of its short half-life. Considerable methemoglobinemia was noted. After subtracting methemoglobin, the hemoglobin rose by 0.4-0.8 g/dl after each 2 units, initially increasing the oxygen binding capacity of the blood by 33%. After a full neurological recovery and weaning from the ventilator but still on hemodialysis, the patient was transferred to another hospital after 38 days.If allogeneic blood transfusion is not an option, administration of polymerized bovine hemoglobin can temporarily increase the oxygen transport capacity as a last resort treatment. Reduction of oxygen requirements by deep inhaled sedation with isoflurane also seems beneficial and provides advantages.Eine 29-jährige Zeugin Jehovas erlitt nach intrauterinem Fruchttod in der 25. Schwangerschaftswoche ein akutes Nierenversagen und eine schwere Anämie, bedingt durch Blutverlust und Hämolyse, erlitt. Wegen ihrer religiösen Überzeugung lehnte die Patientin Bluttransfusionen kategorisch ab. Trotz Umsetzung aller Empfehlungen des Patient Blood Management fiel der Hämoglobin(Hb)-Wert kontinuierlich. Am Tag 10 wurde sie bei Hb 1,9 g/dl plötzlich bewusstlos und musste intubiert und beatmet werden. Wegen organprotektiver Effekte und der guten Steuerbarkeit wurde sie inhalativ mit Isofluran sediert. Isofluran ermöglichte jeweils eine rasche neurologische Beurteilbarkeit in Sedierungsfenstern sowie eine regelmäßige, ruhige Spontanatmung bei tiefer Sedierung mit reduziertem Sauerstoffverbrauch. Als Ausdruck einer posthypoxischen Enzephalopathie zeigte sie in den Sedierungsfenstern Krampfanfälle, die im EEG bestätigt und antikonvulsiv behandelt wurden. Bei Hb 1,8 g/dl erhielt sie 2 Infusionsbeutel mit polymerisiertem bovinem Hämoglobin (Hemopure®, Fa. Hemoglobin Oxygen Therapeutics LLC, Souderton, PA, USA), wegen der kurzen Halbwertszeit mehrmals wiederholt an den Folgetagen. Eine beachtliche Methämoglobinämie wurde festgestellt. Auch nach Abzug des Met-Hb zeigten sich Hb-Anstiege um 0,4–0,8 g/dl nach den Gaben. Die Sauerstoffbindungskapazität des Blutes konnte damit initial um 33 % gesteigert werden. Es kam zu einer vollständigen neurologischen Erholung, und die Patientin wurde schließlich vom Respirator entwöhnt, jedoch weiterhin dialysepflichtig nach 38 Tagen in eine andere Klink verlegt.Wenn die Gabe von Fremdblut keine Option darstellt, kann durch Gabe von polymerisiertem bovinem Hämoglobin als Ultima-Ratio-Therapie die Sauerstofftransportkapazität vorübergehend erhöht werden. Eine inhalative Sedierung mit Isofluran zur Senkung des Sauerstoffverbrauchs erscheint gleichermaßen vorteilhaft.

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.

Hintergrund Der Stellenwert von Dexamethason als Adjuvans in der peripheren Regionalanasthesie ist aktuell unklar.

The updated version of the S2k guidelines on diagnostics and therapy of venous thrombosis and pulmonary embolism have been available since the end of last year. The guidelines deal with the advantages and disadvantages of the currently available investigation and treatment methods, the diagnostic sequence of investigations under various clinical conditions, the invasiveness and duration of therapies and the potential special features of vulnerable patient collectives. This article presents a summary of the most important assertions.

Analysis of exhaled air is a risk-free option for bedside diagnostics. Modern breath analysis can detect very low concentrations of volatile components. Current research focuses on drug monitoring and diagnosis of various diseases.Presentation and discussion of current breath research relevant to intensive care medicine.The literature in PubMed was searched using the following terms: "breath analysis", "volatile organic compounds", "critically ill" combined with "drug monitoring", "propofol", "heart failure", "pneumonia", "ARDS", "renal failure", "liver failure", "sepsis" or "hemorrhage".Intravenously administered propofol can now be measured reliably in exhaled air. Functional impairments of the heart, lungs, kidneys and liver show characteristic influences on the exhaled air, which could serve as a new diagnostic tool in the future. Animal experiments already show promising results to detect sepsis, hemorrhage and ventilator-induced lung injury.In the future, modern breath analysis could enable non-invasive drug monitoring and diagnostics of medical conditions relevant to intensive care medicine.

In der operativ chirurgischen Grundversorgung hat sich die laparoskopische Operationstechnik in den letzten Jahren fest etabliert. Inzwischen werden in der Normalpopulation uber 90 % aller Cholezystektomien und uber 80 % aller Appendektomien minimalinvasiv durchgefuhrt. Die nachgewiesenen Vorteile der laparoskopischen Operationstechnik liegen gegenuber konventionell offenen Operationen in einer vergleichsweise schnelleren fruhpostoperativen Erholung mit fruhzeitiger Wiederaufnahme der allgemeinen korperlichen sowie beruflichen Aktivitat. Da diese Vorteile gleichermasen fur notwendige Eingriffe wahrend einer Schwangerschaft nachweisbar sind, wurde in den letzten Jahren auch wahrend der Schwangerschaft zunehmend minimalinvasiv aus nicht geburtshilflicher Indikation operiert. Insgesamt ist davon auszugehen, dass derartige Eingriffe bei ca. 2 % der schwangeren Patientinnen durchgefuhrt werden mussen. Zahlreiche Studien konnten dabei belegen, dass der Einsatz laparoskopischer Techniken insbesondere fur die werdende Mutter sicher und nicht mit einem erhohten Risiko verbunden ist. Auf der anderen Seite macht die bestehende Schwangerschaft ein adaptiertes Vorgehen bei der Losung chirurgischer Probleme erforderlich, um den Schutz des ungeborenen Kindes zu gewahrleisten. Unter Zugrundelegung der aktuell verfugbaren Datenlage werden Empfehlungen formuliert, die fur eine Vielzahl klinischer Situationen als Entscheidungshilfe herangezogen werden konnen.

Zusammenfassung Hintergrund: Im Rahmen einer Augenoperation hat die Wahl des nicht depolarisierenden Muskelrelaxans für die Intubationsnarkose (ITN) einen erheblichen Einfluss auf das Absinken des intraokularen Druckes (IOD) und der okulären Pulsamplitude (OPA). Patienten und Methoden: Bei 229 Patienten, die für ihre Operation eine ITN benötigten, wurden mithilfe des dynamischen Konturtonometers (DCT) der IOD und die OPA vor und nach Narkoseeinleitung gemessen. Für die ITN wurden die 3 nicht depolarisierenden Muskelrelaxanzien Mivacurium (n = 71), Atracurium (n = 91) und Rocuronium (n = 67) verwendet und deren Einfluss auf IOD und OPA verglichen. Ergebnisse: Der IOD fiel bei Mivacurium um 4,0 ± 2,3 mmHg, bei Atracurium um 6,1 ± 2,2 mmHg und bei Rocuronium um 7,4 ± 1,7 mmHg (p

There is a tremendous amount of variation (heterogeneity) in terms of both symptom presentation and functional ability in individuals with autism spectrum disorder (ASD). The challenges faced by adolescents and emerging adults with ASD can be better understood by considering the unique sociocultural changes that most individuals experience within these stages. In general, adolescents and young adults with ASD have poor social relationship, employment, post–secondary, and independent living outcomes. Additional research efforts, particularly large-scale studies, are needed to better understand the experiences and outcomes of adolescents and young adults with ASD.

Regional anesthesia has undergone many changes over the years and the increasing use of ultrasound has certainly played an important role in this. Apart from individual case reports in the literature of very different blocking options, some new procedures seem to have become established and can be broadly applied. Among these are blockades, by which ultrasound-guided injection of local anesthetics is carried out in fascial or muscular layers rather than around target nerves (e.g. cervical plexus blocks and truncal blocks). In addition, the precision with which ultrasound can be used to identify nerve structures led to an increasingly better definition of targets exemplified for interscalene or femoral nerve blocks. The use of ultrasound also seems to be helpful in the performance of neuraxial blocks, particularly in obese patients or patients with a difficult anatomy. With the implementation 10 years ago of a registry for safety in regional anesthesia and acute pain therapy by the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthesiologists (BDA), it has been possible to answer important safety questions and define protective measures (e.g. tunnelling, antibiotic prophylaxis and sedation). Moreover, this registry can be used as a benchmark to compare the quality of regional anesthesia in individual hospitals with all other participating centers.

In order to avoid chronification of pain, appropriate treatment has to be started as early as possible. Inpatient dermatology patients not only suffer from old age and associated multimorbidities but also from characteristic pain due to distinct dermatological diseases. In many cases clinicians have little experience with specific pain treatment but instead have many concerns about how to deal with analgesics. So far chronic pain has been treated according to the pain ladder of the World Health Organization (WHO), which prioritizes the intensity of pain. This article presents an easily implementable concept of pain therapy with special emphasis on the quality of pain. This provides information on whether it is neuropathic or nociceptive pain, which can ultimately be differentially treated. The primary aim is to provide treating dermatologists with a concept to assist in the initiation of an efficient and correct pain therapy. This brief introduction of an individualized pain treatment can reduce the risk of chronification of pain, which can severely impair the quality of life particularly in dermatology patients and also the frequent stigmatization due to the dermatosis.

Neglect-like symptoms (NLS) describe the experience of perceiving a limb as foreign and could be detected in chronic pain disorders as well as after knee joint replacement. The aim of the present study was to find out whether patients with and without NLS after surgery of the upper extremities differ with respect to pain intensity and psychosocial variables and if NLS are associated with chronic postoperative pain (CPSP).In this study 241 patients were interviewed using a validated questionnaire preoperatively as well as 1 day, 4 weeks, 3 months and 6 months postoperatively. Patients with and without NLS were compared using the χThe NLS could be found to a slight extent throughout the entire study period. Patients with NLS showed significantly higher maximum pain scores at every measurement time point: average difference (∆ = 3, adjusted p 0.005), a higher impairment due to pain (∆ = 15, adjusted p 0.005), more anxiety (∆ = 3, adjusted p 0.005), depression (∆ = 3, average adjusted p 0.003) and kinesiophobia (∆ = 4, preoperative not significant, average postoperative adjusted p = 0.004). Preoperatively, more stressful life events (p = 0.002) and higher stress values (p 0.001) were reported. In patients with CPSP, NLS occurred significantly more often (74%) than in patients without clinically relevant pain (17.5%. p 0.001).The occurrence of NLS is associated with higher pain scores, more impairment due to pain and a higher psychosocial burden and they are more frequent in patients with CPSP. Further investigations are needed to show if NLS are an independent risk factor for the chronification of pain and if NLS play an independent role in the pathogenesis of pain.

The circle system has been in use for more than 100 years, whereas the first clinical application of an anaesthetic reflector was reported just 15 years ago. In the circle system, all breathing gas is rebreathed after carbon dioxide absorption. A reflector, on the other hand, with the breathing gas flowing to and fro, specifically retains the anaesthetic during expiration and resupplies it during the next inspiration. A high reflection efficiency (number of molecules resupplied/number of molecules exhaled, RE 80-90%) decreases consumption. In analogy to the fresh gas flow of a circle system, pulmonary clearance ((1-RE) × minute ventilation) defines the opposition between consumption and control of the concentration.It was not until reflection systems became available that volatile anaesthetics were used routinely in some intensive care units. Their advantages, such as easy handling, and better ventilatory capabilities of intensive care versus anaesthesia ventilators, were basic preconditions for this. Apart from AnaConDa™ (Sedana Medical, Uppsala, Sweden), the new MIRUS™ system (Pall Medical, Dreieich, Germany) represents a second, more sophisticated commercially available system.Organ protective effects, excellent control of sedation, and dose-dependent deep sedation while preserving spontaneous breathing with hardly any accumulation or induction of tolerance, make volatile anaesthetics an interesting alternative, especially for patients needing deep sedation or when intravenous drugs are no longer efficacious.But obviously, the outcome is most important. We know that deep intravenous sedation increases mortality, whereas inhalational sedation could prove beneficial. We now need prospective clinical trials examining mortality, but also the psychological outcome of those most critically ill patients sedated by inhalation or intravenously.

Die Intraokulardruck (IOD)-Messung in Intubationsnarkose (ITN) ist im Rahmen der Glaukomdiagnostik bei Kindern und in ihrer Kooperation beeintrachtigten Patienten ein wichtiges diagnostisches Mittel. Der IOD kann jedoch durch die ITN erheblich verfalscht werden. Die vorliegende Studie evaluiert das Mas des IOD-Abfalls durch eine ITN. Der IOD wurde bei 229 Patienten am nicht zu operierenden Auge im Liegen vor und 5 min nach Einleitung der ITN mit dem dynamischen Contour-Tonometer (DCT) gemessen. Der IOD fiel von 19,9 ± 3,7 mmHg vor ITN auf 14,1 ± 3,5 mmHg 5 min nach ITN-Einleitung (p

Mit der Einfuhrung der ultraschallgestutzten Regionalanasthesie sind die Visualisierung und Verifizierung von Nervenstrukturen weiter in den Fokus des Anasthesisten geruckt. Dieser Beitrag gibt einen kritischen Uberblick uber technische Innovationen in der Regionalanasthesie im Hinblick auf die Optimierung der Nadelfuhrung, die Verbesserung der Nadelsichtbarkeit im Ultraschall genauso wie die technischen Verbesserungen der Ultraschalltechnik und innovative Verfahren in der Regionalanasthesie. Dabei werden bereits in der klinischen Routine verfugbare Losungen, aber auch noch experimentelle Techniken vorgestellt. Mechanische Nadelfuhrungen sorgen fur die optimale Ubereinstimmung von Nadel- und Bildachse des Ultraschallstrahls. „Compound-imaging“-Verfahren erhohen die Nadelsichtbarkeit bei steilen Punktionswinkeln und sind ebenfalls bereits in klinischer Verwendung. Die Sonoelastographie ermoglicht die Detektion kleiner Flussigkeitsmengen und eine verbesserte Gewebediskrimination. Der Nutzen der 3D- bzw. 4D-Sonographie in der Regionalanasthesie wird ebenso diskutiert wie experimentelle Verfahren zur Gewebeerkennbarkeit, z. B. die optische Reflexionsspektrophotometrie.

The German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin, DGAI) established an expert panel to develop preliminary recommendations for nerve localization in peripheral regional anesthesia. Based on expert knowledge and the relatively limited data, the recommendations state how ultrasound and/or electrical nerve stimulation should be used in daily practice, and where and when local anesthetics should be injected. Moreover, it was defined under which conditions a peripheral nerve block under general anesthesia or deep sedation is applicable. Regarding the use of ultrasound the expert opinion was that out-of-plane and in-plane-techniques can be considered equal with respect to patient safety. Nevertheless, the direct or indirect visualization of the needle tip has to be assured. The injection of local anesthetics has to be visualized. Injections into nerves or those requiring an injection pressure should be avoided. The sole use of electrical nerve stimulation or ultrasound for nerve localization is still a suitable option as well as their combined use. To avoid accidental intraneural needle placement, an electrical current threshold ≥ 0.5 mA should be used. Moreover, it was stated that peripheral nerve blocks or continuous nerve block techniques under sedation or general anesthesia are applicable in adult patients who are unable to tolerate the block being performed in an awake state or have difficulty cooperating. This article is published in English.

Die periphere elektrische Nervenstimulation ist neben der Ultraschalltechnik das Standardverfahren zur Durchfuhrung der Blockade peripherer Nerven. In den letzten Jahren sind u. a. durch die Visualisierung von Nadel und Nerv mit Ultraschall wahrend der Blockade klinisch bedeutsame neue Erkenntnisse uber die elektrische Nervenstimulation in den Vordergrund geruckt. Im vorliegenden Beitrag werden die alten und neuen Erkenntnisse in den Grundlagen sowie der Anwendung der Nervenstimulationstechnik dargestellt und in einen klinischen Gesamtkontext gebracht, um sichere und erfolgreiche periphere Blockaden mit der elektrischen Nervenstimulation durchzufuhren.

Cardiac atrophy as a consequence of mechanical unloading develops following exposure to microgravity or prolonged bed rest. It also plays a central role in the reverse remodelling induced by left ventricular unloading in patients with heart failure. Surprisingly, the intracellular Ca(2+) transients which are pivotal to electromechanical coupling and to cardiac plasticity were repeatedly found to remain unaffected in early cardiac atrophy. To elucidate the mechanisms underlying the preservation of the Ca(2+) transients, we investigated Ca(2+) cycling in cardiomyocytes from mechanically unloaded (heterotopic abdominal heart transplantation) and control (orthotopic) hearts in syngeneic Lewis rats. Following 2 weeks of unloading, sarcoplasmic reticulum (SR) Ca(2+) content was reduced by ~55 %. Atrophic cardiac myocytes also showed a much lower frequency of spontaneous diastolic Ca(2+) sparks and a diminished systolic Ca(2+) release, even though the expression of ryanodine receptors was increased by ~30 %. In contrast, current clamp recordings revealed prolonged action potentials in endocardial as well as epicardial myocytes which were associated with a two to fourfold higher sarcolemmal Ca(2+) influx under action potential clamp. In addition, Cav1.2 subunits which form the pore of L-type Ca(2+) channels (LTCC) were upregulated in atrophic myocardium. These data suggest that in early cardiac atrophy induced by mechanical unloading, an augmented sarcolemmal Ca(2+) influx through LTCC fully compensates for a reduced systolic SR Ca(2+) release to preserve the Ca(2+) transient. This interplay involves an electrophysiological remodelling as well as changes in the expression of cardiac ion channels.

Nervenschaden nach peripherer Regionalanasthesie sind seltene und meist passagere Ereignisse. Den exakten Stellenwert der Anlage einer peripheren Regionalanasthesie in Allgemeinanasthesie als Risikofaktor fur Nervenschaden auszumachen, bleibt schwierig und wird kontrovers diskutiert. Aufgrund publizierter Fallberichte, bei denen eine Korrelation zwischen dem Auftreten von Parasthesien beim Anlegen der peripheren Blockade mit neu aufgetretenen neurologischen Defiziten korrelierte, lasst sich die Empfehlung ableiten, periphere Regionalanasthesieverfahren bei Erwachsenen bevorzugt am wachen oder leicht sedierten Patienten durchzufuhren. Fundierte wissenschaftliche Evidenz liegt derzeit allerdings nicht vor. Ob ein anasthesierter oder tief sedierter Patient einem hoheren Risiko bei der Anlage einer peripheren Nervenblockade fur einen Nervenschaden ausgesetzt ist, lasst sich nicht belegen. Dadurch eroffnet sich dem Anasthesisten die Moglichkeit, die personlich bevorzugte Vorgehensweise bei der Durchfuhrung der Regionalanasthesie umzusetzen, ohne gleich dem Verdacht einer Fehlbehandlung ausgesetzt zu sein. Das Risiko einer Intoxikation mit Lokalanasthetika wird durch die Durchfuhrung einer Regionalanasthesie am anasthesierten oder tief sedierten Patienten nicht erhoht. Fur Kinder und nichtkooperative erwachsene Patienten ist die Anlage einer Regionalanasthesie in Narkose oder tiefer Sedierung auch bisher als adaquates Verfahren akzeptiert.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

Chief emergency physicians are regarded as an important element in the care of the injured and sick following mass casualty accidents. Their education is very theoretical; practical content in contrast often falls short. Limitations are usually the very high costs of realistic (large-scale) exercises, poor reproducibility of the scenarios, and poor corresponding results.To substantially improve the educational level because of the complexity of mass casualty accidents, modified training concepts are required that teach the not only the theoretical but above all the practical skills considerably more intensively than at present. Modern training concepts should make it possible for the learner to realistically simulate decision processes. This article examines how interactive virtual environments are applicable for the education of emergency personnel and how they could be designed.Virtual simulation and training environments offer the possibility of simulating complex situations in an adequately realistic manner. The so-called virtual reality (VR) used in this context is an interface technology that enables free interaction in addition to a stereoscopic and spatial representation of virtual large-scale emergencies in a virtual environment. Variables in scenarios such as the weather, the number wounded, and the availability of resources, can be changed at any time. The trainees are able to practice the procedures in many virtual accident scenes and act them out repeatedly, thereby testing the different variants.With the aid of the "InSitu" project, it is possible to train in a virtual reality with realistically reproduced accident situations. These integrated, interactive training environments can depict very complex situations on a scale of 1:1. Because of the highly developed interactivity, the trainees can feel as if they are a direct part of the accident scene and therefore identify much more with the virtual world than is possible with desktop systems.Interactive, identifiable, and realistic training environments based on projector systems could in future enable a repetitive exercise with changes within a decision tree, in reproducibility, and within different occupational groups. With a hard- and software environment numerous accident situations can be depicted and practiced. The main expense is the creation of the virtual accident scenes. As the appropriate city models and other three-dimensional geographical data are already available, this expenditure is very low compared with the planning costs of a large-scale exercise.

The updated version of the S2k guidelines on diagnostics and therapy of venous thrombosis and pulmonary embolism have been available since the end of last year. The guidelines deal with the advantages and disadvantages of the currently available investigation and treatment methods, the diagnostic sequence of investigations under various clinical conditions, the invasiveness and duration of therapies and the potential special features of vulnerable patient collectives. This article presents a summary of the most important assertions.

Obstetric analgesia and anesthesia have some specific aspects, which in particular are directly related to pathophysiological alterations during pregnancy and also to the circumstance that two or even more individuals are always affected by complications or therapeutic measures. This review article deals with some evergreens and hot topics of obstetric anesthesia and essential new knowledge on these aspects is described. The article summarizes the talks given at the 16th symposium on obstetric anesthesia organized by the Scientific Committee for Regional Anaesthesia and Obstetric Anaesthesia within the German Society of Anaesthesiology. The topics are in particular, special features and pitfalls of informed consent in the delivery room, challenges in education and training in obstetric anesthesia, expedient inclusion of simulation-assisted training and further education on risk minimization, knowledge and recommendations on fasting for the delivery room and cesarean sections, monitoring in obstetric anesthesia by neuraxial and alternative procedures, the possibilities and limitations of using ultrasound for lumbal epidural catheter positioning in the delivery room, recommended approaches in preparing peridural catheters for cesarean section, basic principles of cardiotocography, postoperative analgesia after cesarean section, the practice of early bonding in the delivery room during cesarean section births and the management of postpartum hemorrhage.

AIM Gonadal steroids as well as glucocorticoids have been shown to regulate the cardiac L-type Ca(2+) current (I(CaL) ). Herein, we compare the effects of the gonadal steroids testosterone and 17β-estradiol with the glucocorticoid corticosterone on I(CaL) , and investigate the interaction between the gonadal steroids and corticosterone. METHODS Myocytes were isolated from the left ventricular free wall of female and male Wistar rats and investigated using the ruptured-patch whole-cell patch-clamp technique. RESULTS In myocytes isolated from female rats, 24 h incubation with 100 nm testosterone led to a 33% increase in I(CaL) compared with control (-8.8 ± 0.5 pA pF(-1) , n = 25 vs. -6.6 ± 0.4 pA pF(-1) , n = 26, P