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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]

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]

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 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]

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]

A case of in-hospital thoracotomy with subsequent open chest cardiopulmonary resuscitation of a polytraumatized patient is reported. Emergency thoracotomies are rare interventions in challenging situations. Up to now there are only few standards or uniform education and training concepts. The indications are often a borderline decision. The aim of thoracotomy and open resuscitation in combination with a reduction in circulation, for example by cross-clamping the aorta, is to save time to address reversible causes of the hemorrhage, redirect the blood volume into the vital cerebral and coronary circulation and minimize bleeding from subdiaphragmatic bleeding sources. Ultimately, in case of doubt, the thoracotomy can be performed for the patient's benefit with the appropriate indications., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Postoperative vasoplegia with minimal responsiveness to vasopressors is common after cardiac surgery. Called cardiac vasoplegic syndrome (CVS), it is caused by multiple factors. Treating CVS involves a high dose of fluids and catecholamines, however high doses of catecholamines and fluids are associated with serious side effects. There is evidence that new therapeutic strategies can lead to a reduction in norepinephrine doses and mortality in CVS. Specifically, the use of non-adrenergic vasopressors such as methylene blue (MB) can be beneficial., Methods: We retrospectively analyzed the electronic records of 8716 adult cardiac surgery patients from November 2008 to December 2016. Medication, hemodynamic and outcome parameter data were analyzed for CVS until discharge. We determined CVS according to the following parameters: a postoperative onset of ≤24 h, a reduced mean arterial pressure (MAP) of < 70 mmHg, a dose of norepinephrine ≥0.8 mg*h - 1 and a continuously increasing need for catecholamine, without ventricular dysfunction., Results: We identified 513 patients with CVS. Perioperative risk factors were higher in patients treated with methylene blue (MB). Before MB administration patients had a significantly higher dose of norepinephrine, and MAP increased after MB administration. Norepinephrine could be reduced after MB administration and MAP remained stable at the same level even after the reduction of norepinephrine., Conclusions: CVS patients have a severe systemic disease accompanied by significant operative stress and a high catecholamine requirement. The administration of MB in addition to standard treatment for CVS in the first 24 h was accompanied by an increase in MAP followed by a decrease in vasopressor requirement, indicating that early MB administration can be beneficial., (© 2021. The Author(s).)

Objectives: Transcatheter aortic valve implantation (TAVI) is performed in elderly patients with severe aortic valve stenosis and increased operative risks. We tested the hypothesis that acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) have a predictive value for prevalent complications after TAVI and could serve as indicators of systemic inflammation in the early postoperative period., Design: Prospective observational study., Setting: This study is a secondary analysis of multicentre CESARO- study., Participants: 48 patients with TAVI were included and 43 obtained the complete assessment., Primary and Secondary Outcome Measures: Patients' clinical parameters, demographic data, peripheral AChE and BChE activities and routine blood markers were assessed throughout the perioperative period using bedside point-of-care measurements for AChE and BChE. Postoperative complication screening was conducted up to the third postoperative day and included infections, delirium and heart-rhythm disturbances. After assessment, the patients were divided into complication and noncomplication group., Results: Of 43 patients, 24 developed postsurgical complications (55.8%). Preoperative assessment showed no significant differences regarding demographic data and laboratory markers, but preoperative BChE levels were significantly lower in patients who developed postoperative complications (complication group 2589.2±556.4 vs noncomplication group 3295.7±628.0, Cohen's r=0.514, p<0.001). In complication group, we observed an early, sustained reduction in BChE activity from preoperative to postoperative period. In complication group, BChE levels were significantly lower at each time point compared with noncomplication group. AChE activity showed no significant difference between both groups. Complication group also had longer stay in hospital overall., Conclusion: BChE could be a useful perioperative biomarker to identify patients with a higher risk for postoperative complications after TAVI. By using point-of-care measurements, the levels of BChE are fast available and can lead to an early targeted therapy. Predicting the length of the hospital stay might play an important role in staff and resource management for these patients., Trial Registration Number: NCT01964274; Post-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Surgery for acute type A aortic dissection is associated with several perioperative complications, such as acute respiratory dysfunction (ARD). The aim of this study was to investigate perioperative risk factors involved in the development of ARD and whether antibiotic treatment has an impact., Methods: 243 patients underwent surgery for acute type A aortic dissection between 2008 and 2017. The patients were retrospectively divided into the ARD and NON-ARD group. ARD was defined as PaO2/FiO2 ≤ 200 mmHg (PF ratio) within 48 hours after surgery. All patients received either narrow- or broad-spectrum antibiotics., Results: After the exclusion of 42 patients, 201 patients were analyzed. The PF ratio of the ARD group was significantly lower than of the NON-ARD group within the first 7 days. ARD patients (n = 111) were significantly older (p = .031) and had a higher body mass index (BMI) (p = .017). ARD patients required longer postoperative ventilation (2493 vs. 4695 [min], p = .006) and spent more days in the intensive care unit (7.0 vs. 8.9 [days], p = .043) compared to NON-ARD. The mortality was significantly lower for ARD than for NON-ARD patients (p = .030). The incidence of pneumonia was independent of the antibiotic treatment regime (p = .391). Renal and neurological complication rate was higher in patients treated with broad-spectrum antibiotic., Conclusion: ARD is the main complication (55%) that occurs approximately 24 hours after surgery for acute type A aortic dissection. The preoperative risk factors for ARD were higher age and increased BMI. Patients on broad-spectrum antibiotics did not show an improved postoperative outcome compared to patients with narrow-spectrum antibiotics., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study was performed to analyse anaesthesia-related complications and side effects in patients undergoing transcatheter aortic valve implantation (TAVI) under general anaesthesia., Design: Retrospective study., Setting: The study was performed as a single-centre study in a hospital of tertiary care in Germany., Participants: All 853 patients, who underwent TAVI at the Universitätsklinikum Regensburg between January 2009 and July 2015, were included. 52.5% were female patients., Primary and Secondary Outcome Measures: We gathered information, such as recent illness, vital parameters and medication administered during the intervention and postoperatively for 12 hours. We analysed all anaesthesia-related complications and anaesthesia-related side effects that occurred during the intervention and entire hospital stay., Results: We analysed all 853 TAVI procedures. The mean patient age was 79 ± 6 years. In 99.5% of cases, we used volatile-based anaesthesia. 2.8% (n=24; transfemoral (TF): n=19 [3.8%]; transapical (TA): n=5 [1.4%]) of all cases suffered from anaesthesia-related complications. 819 (TF: n=447; TA: n=372) anaesthesia-related side effects occurred in 586 (68.7%, TF: n=325 [64.2%], TA: n=261 [75.2%]) patients. Neither the complications nor the side effects had any serious consequences. Intraoperative hypothermia in 44% of cases (TF: n=202 [39.9%]; TA: n=173 [49.9%]) and postoperative nausea and vomiting in 27% (n=232; TF: n=131 [25.9%], TA: n=101 [29.1%]) of cases were the most common anaesthesia-related side effects., Conclusion: In this study, serious anaesthesia-related complications were rarely seen, and non-critical anaesthesia-related side effects could have been avoided through consistent prophylaxis and management. Therefore, despite their high anaesthetic risk, general anaesthesia is justifiable in patients who underwent TAVI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Recent studies have shown that acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) may serve as important diagnostic and therapeutic targets in sepsis. Since polymorphonuclear neutrophils (PMNs) play a pivotal role in the early phase of sepsis, we evaluated the potential therapeutic effects of cholinesterase inhibitors on PMN functions during cecal ligation and puncture- (CLP-) induced sepsis and investigated the roles of AChE and BChE as inflammatory markers under standardized experimental conditions., Methods: Sham surgery or CLP was performed in male Wistar rats ( n = 60). Animals were randomized into four groups: physostigmine, 100  μ g/kg; neostigmine, 75  μ g/kg; 0.9% saline (control group); and sham group, each applied four times over 24 h. The levels of reactive oxygen species (ROS) production and CD11b/CD62l expression were quantified by flow cytometry at t = 0, 6, 15, 20, and 24 h. Blood gas analysis as well as AChE and BChE activity levels was measured by validated point-of-care measurements. Clinical scores and survival times were determined., Results: CLP induced a significant increase in ROS production and CD11b upregulation by rat PMNs. Treatment with physostigmine or neostigmine significantly reduced ROS production and CD11b upregulation by PMNs 20 h after CLP induction. In physostigmine-treated animals, survival times were significantly improved compared to the control animals, but not in neostigmine-treated animals. While AChE activity significantly decreased in the control animals at t > 6 h, AChE activity did not change in the sham group. BChE activity decreased at t > 20 h in the control animals., Conclusion: While AChE activity may serve as an acute inflammatory marker, BChE activity shows a delayed decrease. Administration of centrally acting physostigmine in CLP-induced sepsis in rats has protective effects on PMN functions and improves survival times, which may be of interest in clinical practice.

Background: Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat degenerative heart valve disease. The implantation requires a highly specific and interdisciplinary management approach. Currently, TAVI is performed with the patient under local or general anaesthesia., Methods: This study was a retrospective analysis of all TAVI procedures performed at the University Hospital of Regensburg between January 2009 and July 2015. All pre-, intra and postoperative data focusing on perioperative complications were recorded., Results: A total of 853 transfemoral- and transapical-TAVI patients were included in the study. All patients underwent general anaesthesia. The ASA classifications were primarily 3-4. The average logistic EuroScores for the transfemoral- and transapical-TAVI patients were 18 ± 12% and 21 ± 15% (p = 0.002), respectively. The anaesthesia coverage time was 170 ± 49 min., including 37 ± 12 minutes for anaesthetic management. Overall, 458 complications were recorded; with pneumonia, acute renal failure, indication for a permanent pacemaker and non-extubation in the operating theatre the most frequently recorded complications., Conclusion: In the present study, we showed that our patients' outcomes are comparable to those reported in the available literature. Compared to TF, TA patients show an overall worse physical condition as well as a higher perioperative morbidity and mortality. Consequently TA patients need additional care and should only be operated in appropriately experienced medical centres.

Patients undergoing peripheral venoarterial extracorporeal membrane oxygenation have a high risk of lower limb ischemia. In general, regular controls are carried out based on clinical and laboratory parameters in order to quickly detect and treat complications. These controls are challenging due to states of shock, nonpulsatile flow and vasopressor therapy. As additional monitoring the use of near-infrared spectroscopy (NIRS) is described in the literature as being very successful in detecting ischemia. The present article describes the use and possible limitations of NIRS for the diagnostics of peripheral ischemia.

Introduction: Mechanical and morphological ischemia and reperfusion (I/R) injury is reduced in septic hearts. The mechanism behind this "cardioprotection" is less well understood. As adenosine receptors play a major role for cardioprotection in non-septic hearts, we investigated the influence of adenosine receptors in a model of I/R in septic hearts., Methods: SHAM operation or cecal ligation and puncture (CLP) was performed in adult male Wistar rats (n = 60). After 24 h of incubation, hearts were isolated and randomly assigned to a group with or without adenosine receptor (Ador) antagonists (SCH 58261 and MRS 1706) administered before reperfusion. Ischemia and reperfusion lasted for 40 min each. Cardiac function of the heart was determined by measuring left ventricular pressure (LVP)., Results: Before I/R, CLP hearts showed a significant mechanical left ventricular impairment (CLP: 63 ± 5 mmHg vs. SHAM: 104 ± 6 mmHg. After I/R, left ventricular function was significantly reduced in SHAM (24 ± 32 mmHg), but not in CLP hearts (65 ± 13 mmHg). mRNA expression for the AdorA2a and AdorA2b was significantly increased in CLP, but not in SHAM hearts. LVP of CLP hearts deteriorated when AdorA2a and AdorA2b were blocked., Conclusions: The morphological and functional I/R injury in septic animals is less pronounced compared to non-septic animals. By a combined blockade of AdorA2a and AdorA2b this "cardioprotective" effect is nearly abolished in septic hearts. This is the first study showing, that AdorA2a and AdorA2b may play an important role for a reduced functional I/R injury in the septic heart., Competing Interests: Compliance with Ethical Standards Disclosure of Funding Supported by an institutional funding of the Department of Anaesthesiology, University hospital of Regensburg. Conflict of Interest None.

Previous and more recent studies show that cholinesterase inhibitors (ChE-Is) are an important possibility for therapeutic intervention in Alzheimer's Disease, sepsis and other inflammatory syndromes. ChE-Is maintain high levels of acetylcholine (ACh) determining beneficial effects on the disease process. Despite numerous efforts to identify the appropriate choice of agents and dose of ChE-Is, a common protocol regarding concentration- and species-dependent differences in inhibitory potency (IC 50) of clinical relevant ChE-Is is still not available. To evaluate the in vitro sensitivity of Acetyl- and Butyrylcholinesterase (AChE, BChE), we compared the concentration-response effects of physostigmine and neostigmine on cholinesterases in whole blood from rat and human. A spectrophotometrical test system based on in vitro Ellman's reagent has been used to determine the kinetic properties of clinical relevant ChE-Is. In vitro, the enzyme activity of human AChE and BChE was inhibited in a concentration-dependent manner until a residual activity of 4-6% for AChE and 20-30% for BChE (IC 50 human AChE: 0.117 ± 0.007 μM physostigmine, 0.062 ± 0.003 μM neostigmine; IC 50 human BChE: 0.373 ± 0.089 μM neostigmine; 0.059 ± 0.012 μM physostigmine). The inhibition curve of rat BChE in contrast showed no concentration-dependency for physostigmine and neostigmine (87% residual activity even at high inhibitor concentrations). Rat AChE was inhibited in a concentration-dependent manner until a residual activity of 53%. The results suggest that cholinesterases from human and rat show marked species- and inhibitor-dependent differences in sensitivity to physostigmine and neostigmine. Knowledge of such differences may be critical in assessing the possible therapeutic effects of ChE-Is in both species and may guide researchers in the optimal design of future experiments regarding the application of ChE-Is., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Baroreceptor stimulators are novel implantable devices that activate the carotid baroreceptor reflex. This results in a decrease in activity of the sympathetic nervous system and inhibition of the renin-angiotensin-aldosterone system. In patients with drug-resistant hypertension, permanent electrical activation of the baroreceptor reflex results in blood pressure reduction and cardiac remodeling. For correct intraoperative electrode placement at the carotid bifurcation, the baroreceptor reflex needs to be activated several times. Many common anesthetic agents, such as inhalation anesthetics and propofol dampen or inhibit the baroreceptor reflex and complicate or even prevent successful placement. Therefore, a specific anesthesia and pharmacological management is necessary to ensure successful implantation of baroreceptor reflex stimulators.

Due to a huge increase in the implantation of ventricular assist devices (VAD) over the last few years and the enormous technical advances in functional safety, a growing number of patients with VAD are discharged from hospital, who are still considered to be severely ill. This results in an increased probability of these patients interacting with emergency services where personnel are unaware of the presence of a VAD, creating anxiety and uncertainty regarding how to treat these patients. This article presents an overview of the most common problems and pitfalls regarding VADs. It also presents an algorithm for dealing with emergencies involving these patients including the diagnostics, treatment and primary transport.

Background: Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally., Aim: This article presents the preparation of recommendations in the training and development of palliative care emergency situations., Material and Methods: A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results., Results: Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature., Conclusion: The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.

Background: Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate., Methods: We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management., Results: Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics., Conclusion: This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Background: The use of lipid emulsions to reduce cardiac toxicity of local anaesthetics (LAs) has shown success in experimental studies and some clinical cases, and thus has been implemented in clinical practice. However, lipid treatment is usually given after the occurrence of neurological or cardiovascular symptoms of systemic intoxication. The aim of this study was to determine if pretreatment with lipid emulsion reduces cardiac toxicity produced by bupivacaine or mepivacaine., Methods: Isolated rat hearts were perfused with or without lipid emulsion (0.25 ml kg(-1) min(-1)) before administration of equipotent doses of bupivacaine (250 µM) or mepivacaine (1000 µM). Haemodynamic parameters and times from start of perfusion LA to a 1 min period of asystole and recovery were determined., Results: Pretreatment with lipid emulsion extended the time until occurrence of asystole and decreased times to recovery in bupivacaine-induced cardiac toxicity but not in mepivacaine-induced cardiac toxicity compared with control. Lipid pretreatment impaired rate-pressure product recovery in mepivacaine-intoxicated hearts., Conclusions: This study confirms that pretreatment with a lipid emulsion reduces cardiac toxicity of LAs. The efficacy of pretreatment with lipid emulsion was LA-dependent, so pharmacokinetic properties, such as lipophilicity, might influence the effects of lipid emulsion pretreatment.

Background: Cardiovascular resuscitation upon intoxication with lipophilic ion channel-blocking agents has proven most difficult. Recently, favorable results have been reported when lipid rescue therapy is performed, i.e., the infusion of a triglyceride-rich lipid emulsion during resuscitation. However, the mechanism of action is poorly understood., Methods: The authors investigate the effects of a clinically used lipid emulsion (Lipovenös® MCT 20%; Fresenius Kabi AG, Bad Homburg, Germany) on the block of the fast Na current (INa) induced by the lipophilic local anesthetic bupivacaine in adult rat left ventricular myocytes by using the whole cell patch clamp technique., Results: Bupivacaine at 10 µm decreased INa by 54% (-19.3 ± 1.9 pApF vs. -42.3 ± 4.3 pApF; n = 17; P < 0.001; VPip = -40 mV, 1 Hz). Addition of 10% lipid emulsion in the presence of bupivacaine produced a 37% increase in INa (-26.4 ± 2.8 pApF; n = 17; P < 0.001 vs. bupivacaine alone). To test whether these results could be explained by a reduction in the free bupivacaine concentration by the lipid (lipid-sink effect), the authors removed the lipid phase from the bupivacaine-lipid mixture by ultracentrifugation. Also, the resulting water phase led to an increase in INa (+19%; n = 17; P < 0.001 vs. bupivacaine), demonstrating that part of the bupivacaine had been removed during ultracentrifugation. The substantially less lipophilic mepivacaine (40 µm) reduced INa by 27% (n = 24; P < 0.001). The mepivacaine-lipid mixture caused a significant increase in INa (+17%; n = 24; P < 0.001). For mepivacaine, only a small lipid-sink effect could be demonstrated (+8%; n = 23; P < 0.01), reflecting its poor lipid solubility., Conclusion: The authors demonstrate lipid rescue on the single-cell level and provide evidence for a lipid-sink mechanism.

Objectives: Based on continuous technical innovations and recent research, extracorporeal membrane oxygenation (ECMO) has become a promising tool in the treatment of patients with acute (cardio)pulmonary failure. Nevertheless, any extracorporeal technique requires a high degree of experience and knowledge, so that a restriction to specialized centres seems to be reasonable. As a consequence of this demand, the need for inter-hospital transfer of patients with severely impaired (cardio)pulmonary function is rising. Unfortunately, most of the ECMO devices used in the clinical setting are not suitable for inter-hospital transport because of their size, weight or complexity. In this article, we describe our first experiences with the airborne transport of 6 patients on a new portable, miniaturized and lightweight extracorporeal circulation system, the Medos deltastream® DP3., Methods: Six patients suffering acute respiratory failure were taken on venovenous ECMO (DP3) out-of-centre and transferred to the University Medical Center Regensburg by helicopter. All cardiorespiratory-relevant parameters of the patients and the technical functioning of the device were continuously monitored and documented., Results: Implantation of the device and air-supported transport were performed without any technical complications. The patients were transported from a distance of 66-178 km, requiring a time of 40-120 min. With the help of the new deltastream® DP3 ECMO device, a prompt stabilization of the cardiopulmonary function could be achieved in all patients. One patient was under ongoing cardiopulmonary resuscitation by the time our ECMO team arrived at the peripheral hospital and died shortly after arrival in the central emergency ward., Conclusions: Our experience shows that the deltastream® DP3 is an absolutely reliable and safe ECMO device that could gain growing importance in the field of airborne transportation of patients on ECMO due to its unsophisticated, miniaturized and lightweight characteristics.

Introduction: Recent data suggested an interaction between plasma constituents and the endothelial glycocalyx to be relevant for vascular barrier function. This might be negatively influenced by infusion solutions, depending on ionic composition, pH and binding properties. The present study evaluated such an influence of current artificial preparations., Methods: Isolated guinea pig hearts were prepared in a modified Langendorff mode and perfused with Krebs-Henseleit buffer augmented with 1g% human albumin. After equilibration the perfusion was switched to replacement of one half buffer by either isotonic saline (NaCl), ringer's acetate (Ri-Ac), 6% and 10% hydroxyethyl starch (6% and 10% HES, resp.), or 4% gelatine (Gel), the artificial colloids having been prepared in balanced solution. We analysed glycocalyx shedding, functional integrity of the vascular barrier and heart performance., Results: While glycocalyx shedding was not observed, diluting albumin concentration towards 0.5g% by artificial solutions was associated with a marked functional breakdown of vascular barrier competence. This effect was biggest with isotonic saline and significantly attenuated with artificial colloids, the difference in the pressure dependent transvascular fluid filtration (basal vs. during infusion in groups NaCl, Ri-Ac, 6% HES, 10% HES and Gel, n = 6 each) being 0.31 ± 0.03 vs. 1.00 ± 0.04; 0.27 ± 0.03 vs. 0.81 ± 0.03; 0.29 ± 0.03 vs. 0.68 ± 0.02; 0.32 ± 0.03 vs. 0.59 ± 0.08 and 0.31 ± 0.04 vs. 0.61 ± 0.03 g/5min, respectively. Heart performance was directly related to pH value (7.38 ± 0.06, 7.33 ± 0.03, 7.14 ± 0.04, 7.08 ± 0.04, 7.25 ± 0.03), the change in the rate pressure product being 21,702 ± 1969 vs. 21,291 ± 2,552; 22,098 ± 2,115 vs. 14,114 ± 3,386; 20,897 ± 2,083 vs. 10,671 ± 1,948; 21,822 ± 2,470 vs. 10,047 ± 2,320 and 20,955 ± 2,296 vs. 15,951 ± 2,755 mmHg × bpm, respectively., Conclusions: It appears important to maintain the pH value within a physiological range to maintain optimal myocardial contractility. Using colloids prepared in calcium-containing, balanced solutions for volume replacement therapy may attenuate the breakdown of vascular barrier competence in the critically ill.

Background: Cholinesterase inhibitors (Ch-I) improve survival in experimental sepsis consistent with activation of the cholinergic-anti-inflammatory-pathway. So far, less is known about whether Ch-I have a direct immunomodulatory effect on immune cells (polymorphonuclear neutrophils, PMN) in the absence of cholinergic neurons. We investigated the concentration-response-effects of physostigmine and neostigmine on the oxidative burst activity (human and rat PMN) and the expression of adhesion molecules on the surface of human PMN under in vitro conditions., Methods: PMN from 10 healthy humans or 10 rats were pretreated with 2, 10, 24, 97 μM physostigmine or 3, 15, 30, 150 μM neostigmine, primed with tumor-necrosis-factor-alpha (TNF-alpha) followed by stimulation with n-formyl-methionyl-leucylphenylalanine (fMLP) or stimulated with phorbol-12-myristate-13-acetate (PMA). Human and rat samples were assessed by flow cytometry for the generation of oxidative free radicals. Stimulated human PMN were additionally incubated with antibodies against Mac-1 (CD11b) or L-selectin (CD62l)., Results: Physostigmine and neostigmine did not alter oxidative burst activity or the expression of adhesion molecules of PMN induced by receptor-dependent activators like fMLP or TNF-alpha/fMLP (rat and human PMN, p=n.s.). Physostigmine, but not neostigmine, inhibited the protein-kinase-C-mediated oxidative burst activity by PMA in a dose-dependent manner (rat and human PMN, p<0.05). Physostigmine, in the concentration range tested, suppressed the expression of CD11b following stimulation with PMA not significantly (human PMN: control: 63.1±10.7 vs. 97 μM physostigmine: 49.9±12.8 MESF, p=n.s.)., Conclusion: While neostigmine has no effect on functional and phenotypic changes of PMN, the lipid soluble Ch-I physostigmine causes a dose dependent reduction in PMA-induced oxidative burst, independent of neuronal released acetylcholine., (Copyright © 2013 Elsevier GmbH. All rights reserved.)

Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.

Background: In the context of regional anesthesia procedures adverse events rarely occur but are predominantly systemic intoxication due to local anesthetics (0.01-0.035 %), nerve injuries (0.01-1.7 %) and infections (0-3.2 %)., Materials and Methods: In a level 1 trauma centre data from all continuous peripheral nerve blocks (cPNB) were prospectively acquired over a period of 8 years (2002-2009) in an observational study (n = 10,549). The acquisition of data was carried out in an intranet-based data bank which was accessible for 24 h on every anesthesia workstation. The collected data included type of block, catheter duration and accompanying complications. This study was carried out with special respect to infectious complications (inflammation and infection)., Results: In the years 2002-2004 unexpectedly high rates of infectious complications were observed in 3,491 cPNBs with 146 inflammations (4.2 %) and 112 infections (3.2 %). Based on these alarming findings the existing hygiene regime was revised. The innovations were incorporated into the "Hygiene recommendations for the initiation and continued care of regional anaesthetic procedures" of the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI). A major change was the extension of skin disinfection to a spray-and-scrub combined procedure lasting 10 min. The introduction of this care bundle was carried out in 2005. Among 7,053 cPNBs that were conducted between 2005 and 2009 inflammation occurred in only 183 procedures (2.6 %) and infection in 61 procedures (0.9 %). This reduction was highly significant in both categories (p < 0.001). The risk factors catheter duration and catheter localization statistically remained unchanged during the observational period, Conclusion: Using a real-time computer-based tool for data capture makes a veritable detection of adverse events possible. Such a tool also has the power to monitor the effects of changes in clinical procedures (SOP). In this case it was possible to verify the successful introduction of an extended hygiene care bundle. The new regime significantly decreased the rate of infections in cPNB.

Background: The efficiency of cardiopulmonary resuscitation (CPR) training is dependent upon different influencing factors, such as the presented concepts, the participants' willingness to learn, and the interval between training sessions. However, the optimal interval for refreshing CPR training is less clear., Objective: We evaluated the perceived need of simulator-based CPR training for nurses and correlated it with their clinical experience., Methods: The 60 invited nurses were trained in simulator-based CPR. Knowledge about adult advanced life support was evaluated using a questionnaire after training, and participants rated their desired individual frequency of simulator-based training as well as the value of the presented training using a six-point Likert scale. The same questions were asked again after 1 year., Results: All participants agreed about the usefulness of this type of simulator-based training. The average number of correct answers about typical facts in adult advanced life support showed an almost bell-shaped distribution, with the highest point at 6-15 years of clinical experience and the lowest points at≤5 and≥21 years. The desired training-frequency need was inversely correlated with clinical experience., Conclusions: There is a high interest in CPR training among nursing staff. Self-assessment about the training-frequency need was inversely correlated with clinical experience. However, the average number of correct answers on resuscitation questions decreased with clinical experience. Therefore, the training effectiveness seems to be extremely dependent on clinical experience, and therefore, training experienced senior nurses might be more challenging than training novice nurses., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Medical and technical progress together with demographic changes has led to a more complex perioperative care for patients. Accordingly, an optimal preoperative assessment in particular an adequate risk evaluation is more important than ever. A recently published joint recommendation of the German Society of Anaesthesiology and Intensive Care Medicine, the German Society of Surgery and the German Society of Internal Medicine aims to reduce considerable uncertainties in the preoperative risk evaluation especially with regard to"technical tests" by providing transparent and comprehensive arrangements. Consequently, routine screening will be abandoned in favour of targeted patient and operation-oriented individual risk assessment. This approach will change the preoperative risk evaluation in a scientific, organisational and economic way. The following article on preoperative risk evaluation is based on the valuable and helpful recommendation and aims to provide additional important aspects from the perspective of anaesthesiologists.

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.

Background: Anesthesiology departments were often integrated into the primary formation of palliative activities in Germany. The aim of this study was to present the current integration of anesthesiology departments into palliative care activities in Germany., Methods: The objective was to determine current activities of anesthesiology departments in in-hospital palliative care. A quantitative study was carried out based on a self-administered structured questionnaire used during telephone interviews., Results: A total of 168 out of 244 hospitals consented to participate in the study and the response rate was 69%. In-hospital palliative care activities were reported for most of the surveyed hospitals. Only two hospitals in the maximum level of care reported no activities. Participation in these activities by anesthesiology departments was described in up to 92%. Historically, most activities are due to the commitment of individuals, whereas the development of palliative care of cancer pain services and hospital support teams took place in the university hospitals by 2005., Conclusions: Until 2005 many university palliative care activities had their origins in cancer pain services. These were often integrated into anesthesiology departments. Currently, anesthesiology departments work as an integrative part of palliative medicine. However, it appears from the present results that there is a domination of internal medicine (especially hematology and oncology) in palliative activities in German hospitals. This allows the focus of palliative activities to be formed by subjective specialist interests. Such a state seems to be reduced by the integration of anesthesiology departments because of their neutrality with respect to faculty-specific medical interests. Advantages or disadvantages of these circumstances are not considered by the present investigation.

In this case series, we describe our successful use of a reduced hirudin dosage as an anticoagulant during cardiac surgery using minimized extracorporeal circulation in patients with heparin-induced thrombocytopenia., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Coronary artery bypass grafting (CABG) is the gold standard for the surgical therapy of multivessel coronary artery disease. To reduce the side effects, associated with standard extracorporeal circulation (ECC), a concept of minimal extracorporeal circulation (MECC) was devised in our center. We report on our 10-year experience with the MECC for coronary revascularization., Methods: From January 1998 to August 2009, 2243 patients underwent CABG with MECC in our center. In a retrospective observational study, we analyzed indication, preoperative patient co-morbidity, postoperative clinical course, and perioperative outcome of all patients operated on with MECC. Furthermore, the risk factors for mortality in the MECC group were assessed., Results: Patients showed a mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 4.5±0.1%. The mean age of the patients was 66.8±9.1 years. The overall 30-day mortality after CABG with MECC was 2.3%, ranging from 1.1% for elective to 13.0% for emergent patients and was significantly better than standard ECC. Only 15.3% (n=344) of patients with MECC required intra-operative blood transfusion. Postoperative catecholamine support, red blood cell transfusion, need for hemodialysis, release of creatinine kinase, incidence of stroke, and postoperative delirium were low after MECC revascularization. Ejection fraction below 30% (odds ratio (OR): 5.1), emergent operation (OR: 9.4), and high-dose catecholamine therapy (OR: 2.6) were associated predictors for mortality., Conclusion: MECC until now is an established concept and has become an alternative for ECC in routine CABG in our center. The use of the MECC system is associated with low mortality and conversion rate. Excellent survival rates and low transfusion requirements in the perioperative course were achieved., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

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.

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.

Background: Cancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy., Methods: A total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007-2009). The questionnaire was prepared for the study ("mixed methods design"). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well., Results: A total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2-24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5 years answered statistically significantly more questions correctly (p=0.004)., Conclusions: The results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.

In septic patients, myocardial depression-the so-called septic cardiomyopathy-needing inotropic support is common. The aim of this study was to compare the dose-responsive electrophysiological and mechanical properties concerning metabolic effects of clinically available inotropic agents in an isolated septic rat heart model. After 20 h of incubation, both sham-operated and septic (cecal ligation and single puncture) hearts from male Wistar rats (n = 64) were isolated and received dobutamine, dopamine, epinephrine, or levosimendan at concentrations of 10 to 10 M. Electrophysiological, mechanical, and metabolic properties were measured, and the myocardial oxygen supply-demand ratio and cardiac efficiency were calculated. With the exception of levosimendan, all of the drugs tested showed dose-dependent, significantly positive changes in chronotropy, inotropy, and lusitropy in all hearts. Maximum increases in septic hearts were dose-dependent and were ordered as follows: epinephrine > dopamine > dobutamine >>> levosimendan. These increases in cardiac performance were accompanied by a decrease in the myocardial oxygen supply-demand ratio. However, cardiac efficiency was significantly improved in the epinephrine-treated septic hearts. With the drug-induced increase in cardiac performance, the myocardial oxygen supply-demand ratio decreased proportionally in the epinephrine-, dobutamine-, and dopamine-treated septic hearts. However, epinephrine showed the most favorable results with regard to cardiac efficiency, and levosimendan showed no beneficial effect in septic hearts with regard to efficiency in this study.

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.

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.

Background: Cardiac toxicity significantly correlates with the lipophilicity of local anesthetics (LAs). Recently, the infusion of lipid emulsions has been shown to be a promising approach to treat LA-induced cardiac arrest. As the postulated mechanism of action, the so-called "lipid sink" effect may depend on the lipophilicity of LAs. In this study, we investigated whether lipid effects differ with regard to the administered LAs., Methods: In the isolated rat heart, cardiac arrest was induced by administration of equipotent doses of bupivacaine, ropivacaine, and mepivacaine, respectively, followed by cardiac perfusion with or without lipid emulsion (0.25 mL x kg(-1) x min(-1)). Subsequently, the times from the start of perfusion to return of first heart activity and to recovery of heart rate and rate-pressure product (to 90% of baseline values) were assessed., Results: In all groups, lipid infusion had no effects on the time to the return of any cardiac activity. However, recovery times of heart rate and rate-pressure product (to 90% of baseline values) were significantly shorter with the administration of lipids in bupivacaine-induced cardiac toxicity, but not in ropivacaine- or mepivacaine-induced cardiac toxicity., Conclusions: These data show that the effects of lipid infusion on LA-induced cardiac arrest are strongly dependent on the administered LAs itself. We conclude that lipophilicity of LAs has a marked impact on the efficacy of lipid infusions to treat cardiac arrest induced by these drugs.

Background: Analysis of critical incidents in anaesthesia practice emphasizes the important role of non-technical skills (NTS) in improving patient safety. Therefore, debriefing with regard to NTS has been added to medical management (MM) simulator training to improve acute crisis competencies of anaesthesiologists. The purpose of this study was to compare the NTS and MM performance of two groups of anaesthesiologists in a simulated anaesthesia crisis after undergoing different types of training., Methods: Forty-two anaesthesiologists were randomly assigned to two different training groups, with each group participating in two simulation training sessions. One group's (NTS+MMG) training included extensive debriefing of NTS (resource management, planning, leadership and communication) and MM, while the other group (MMG) received a simpler debriefing that focused solely on MM. The quality and quantity of NTS and quality of MM performance were rated by reviewing the videotapes of the scenarios., Results: NTS+MMG did not prove superior to MMG with regard to behavioural and MM markers. The quality of NTS performances correlated significantly (P<0.01) with the quantity of NTS demonstration, and also correlated significantly with the MM actions (P<0.01) in both groups., Conclusion: A single session of training including debriefing of NTS and MM did not improve the NTS performances of anaesthesiologists when compared with anaesthesiologists who only received MM training. This might indicate that a more frequent or individual training is needed to improve participants' NTS performance.