Der Anaesthesist (Anaesthesist)

Publications in this journal

• Article: [Legal position of non-medical personnel in hospitals.]

  M H Kirschner, M Nebendahl, S G Russo, A Tecklenburg, M Bauer
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  ABSTRACT: There are currently many assistant professions in the German healthcare system which have either a more nursing or a more medical character. All these assistant professions have in common that as yet they do not require uniform training criteria but members of these professions undertake some aspects of medical activities. At the center lies the difficulty of more political than legal discussion on whether members of these assistant professions and also nursing personnel are allowed to or should undertake medical activities. This article illuminates the legal status quo.
  Der Anaesthesist 05/2013;
• Article: [Quality of postoperative pain therapy : Evaluation of an established anesthesiology acute pain service.]

  V Kainzwaldner, B Rachinger-Adam, T Mioc-Curic, T Wöhrle, L C Hinske, B Luchting, T Ewert, S C Azad
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  ABSTRACT: BACKGROUND: Despite well-designed concepts of perioperative pain management, recent studies have revealed that a large number of patients still suffer from unacceptable pain after surgery. The purpose of this prospective evaluation was to critically analyze postoperative pain treatment provided by a routinely established, DIN certified acute pain service (APS) at the University Hospital Großhadern in Munich. MATERIALS AND METHODS: A total of 1,000 consecutive patients received one of the following analgesic procedures: continuous epidural analgesia (EA, n = 401), continuous and patient-controlled epidural analgesia (PCEA, n = 305), intravenous patient-controlled analgesia with opioids (PCA, n = 169) or continuous peripheral nerve block (CPNB, n = 125). For EA and PCEA, ropivacaine 0.2 % and sufentanil 0.24 µg/ml were administered while peripheral regional analgesia was performed with infusion of ropivacaine 0.2 % only. Patients with PCEA were allowed a 3 mg bolus once per hour on demand. Standardized intravenous PCA was performed with piritramide 2.5 mg/ml, a bolus of 2.5 mg, a lock-out time of 15 min, a maximum of 25 mg/4 h and no background infusion. During the daily visits the APS assessed pain intensity at rest and during movement on a numerical rating scale from 0 (no pain) to 10 (maximum pain), acceptance of pain, satisfaction with the analgesic procedure, demand of additional non-opioid analgesics, the need for optimization including bolus applications and changes of the infusion rate or retraction of the epidural catheter. The duration of the procedures, side effects and complications were documented. The catheter insertion sites were inspected daily for redness and tenderness on palpation. RESULTS: In general, epidural and peripheral regional analgesic techniques were superior in terms of postoperative analgesia to intravenous opioid PCA and were associated with fewer side effects, such as sedation, nausea, vomiting, obstipation and sensorimotor deficits. A subgroup analysis revealed that in major upper abdominal surgery, EA provided significantly better analgesia at rest and during movement than PCA. In lower abdominal surgery PCEA induced significantly better analgesia than both PCA and EA, especially during movement. Patient satisfaction was generally high and was best with PCEA (95 %) followed by CPNB (94 %), EA (91 %) and PCA (88 %). On the first postoperative day analgesic procedures had to be optimized (e.g. by bolus administration, retraction of catheters or changes to standardized PCA) in 23 % of EA patients, 10 % of PCEA patients, 6 % of PCA patients and 12 % of CPNB patients. Major complications, such as neuraxial hematoma, infections or respiratory depression were not observed. CONCLUSIONS: As described in many prospective studies, this evaluation revealed that for postoperative pain control, regional anesthesia is superior to intravenous patient-controlled analgesia with strong opioids in terms of analgesia and side effects. In the setting of a well-organized acute pain service with frequent education and training of all members involved, postoperative pain management is safe and effective. However, regular re-evaluation of the defined and certified procedures is necessary.
  Der Anaesthesist 05/2013;
• Article: [Anesthesiological acute pain therapy in Germany : Telephone-based survey.]

  C L Lassen, F Link, N Lindenberg, T W Klier, B M Graf, C Maier, C H R Wiese
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  ABSTRACT: INTRODUCTION: The last survey of anesthesiological acute pain therapy in Germany was conducted in 1999. Since then new organisational as well as therapeutic aspects have developed. Amongst others the operation and procedures key (OPS) figure 8-919 complex acute pain therapy has been introduced in the German medical billing system, with the restriction that it cannot currently be redeemed. There is an ongoing debate on the role of epidural analgesia in acute pain therapy and new oral medication concepts have been established. Therefore a survey of the present state of acute pain therapy in Germany was conducted. METHODS: Based on a list of all 1,356 hospitals in Germany a randomized list of 412 hospitals was generated. Out of these 412 hospitals those with anesthesiology departments (378 hospitals) were contacted via telephone and asked to participate in the survey. Out of the 378 hospitals 285 (75.4 %) agreed to take part. The survey consisted of a questionnaire containing closed and open questions regarding organisational and therapeutic aspects of acute pain therapy. The ethics committee of the University of Regensburg rated the survey as not being subject to approval due to the lack of personal patient data. RESULTS: Of the participating hospitals 183 (64.2 %) had an acute pain service (APS) and of these 107 (58.5 %) met the quality criteria of the OPS 8-919. This figure however, was only consistently documented by 40 (37 %) APSs. Epidural analgesia (EA) was offered by 275 (96.5 %) hospitals and patient-controlled intravenous analgesia (PCA) by 255 (89.5 %). Likewise, 255 (89.5 %) hospitals used controlled-released opioids in acute pain therapy. Concerning EA, the medications most used were sufentanil as an opioid and ropivacaine as a local anesthetic in255 (92.7 %) of the hospitals with EA for sufentanil and 253 (92 %] for ropivacaine. An EA was offered on regular wards in 240 (87.3 %) hospitals. Uncertainty existed about concrete limits for coagulation values before removal of an epidural catheter. The opioid most utilized in PCA was piritramide with some hospitals using morphine or oxycodone (92.2 %, 9.4 % and 9.4 %, respectively). Other opioids, such as hydromorphone and tramadol were rarely used and remifentanil was not used at all. Oral medication was widely used with metamizole being the non-opioid analgesic and oxycodone/naloxone the controlled-release opioid being prescribed the most. New antiepileptic drugs, such as gabapentin or pregabalin were rarely employed in acute pain therapy. CONCLUSIONS: Since 1999 the number of hospitals that have implemented an APS has risen from 36.1 % to 64.2 %. The lack of consistent documentation of the OPS 8-919 will probably not increase the likelihood that it will become redeemable in the near future. Certain therapy methods, such as EA and PCA were still well established with oral therapy gaining in significance. The uncertainty regarding limits for coagulation values before removal of an epidural catheter could perhaps be reduced by a statement from the German Society of Anesthesia and Intensive Care.
  Der Anaesthesist 05/2013;
• Article: Bupivacaine crystal deposits after long-term epidural infusion.

  I Balga, H Gerber, X H Schorno, F Aebersold Keller, H-P Oehen
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  ABSTRACT: The case of a 45-year-old male patient (body weight 52 kg, height 1.61 m) with a locally invasive gastric carcinoma infiltrating into the retroperitoneal space is reported. Because of severe cancer pain a tunnelled thoracic epidural catheter (EC) was placed at thoracic spinal level 7/8 and a local anesthetic (LA) mixture of bupivacaine 0.25 % and morphine 0.005 % was infused continuously at 6 ml h(-1). To optimize pain therapy the concentration was doubled (bupivacaine 0.5 %, morphine 0.01 %) 3 months later but the infusion rate was reduced to 3 ml h(-1) thus the total daily dose did not change. The patient died 6 months after initiation of the epidural analgesia from the underlying disease. The total amount of bupivacaine infused was 69 g and of morphine 1.37 g. The patient never reported any neurological complications. The autopsy revealed large white crystalline deposits in the thoracic epidural space which were identified as bupivacaine base by infrared spectrometry. Morphine could not be detected. A histological examination showed unreactive fatty tissue necrosis within the crystalline deposits but nerve tissue could not be identified. It is concluded that the bupivacaine crystalline deposits arose due to precipitation but the clinical significance with regard to sensory level and neuraxial tissue toxicity is unknown.
  Der Anaesthesist 05/2013;
• Article: [On preoperative risk evaluation of adult patients before elective non-cardiac surgery : Results of a survey on clinical practice in the Federal State of Hessen.]

  H Aust, B Veltum, T Wächtershäuser, L Eberhart, H Wulf, D Rüsch
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  ABSTRACT: BACKGROUND: The German Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine and Surgery have recently published for the first time joint recommendations for the evaluation of adult patients prior to elective non-cardiac surgery. In these recommendations indications for preoperative diagnostic procedures were critically revised and updated. It was unclear to what extent these recommendations were known among German anesthesiologists, how the recommendations were perceived and to what extent they were put into practice. The indications of five common diagnostic procedures in the context of the preoperative evaluation were also unknown. METHODS: Three months after publication of the recommendations, all anesthesiologists employed at hospitals in the state of Hessen were requested to take part in an online survey (OS). In the first part of the OS participants were asked about familiarity with the recommendations, opinions concerning the utility of the recommendations and to what extent they were implemented. In the second part of the OS participants were questioned in general and in the context of two common case scenarios about indications for electrocardiograms (ECG), chest radiographs (chest x-ray), echocardiograms, spirometry and extended cardiac diagnostics, such as stress ECG. In addition, participants of the OS were requested to take part in an interview survey (IS) addressing the same topics. The purpose of the IS was to detect any bias caused by the anonymous character of the OS which could lead to an overestimated self-assessment. Answers of the IS were not compared to the results of the corresponding answers given online by the same anesthesiologist but only analyzed together with the other results of the IS for comparison with the results of the OS. RESULTS: Of the contacted anesthesiologists 396 (29 %) took part in the OS of which 100 took part in the IS. According to the OS 30 % were familiar and 34 % were partially familiar with the recommendations, 20 % just knew that recommendations had been published and 16 % did not even know about the publication. The corresponding results of the IS were 16 %, 36 %, 28 % and 20 %, respectively. Of the participants 90 % (OS) and 89 % (IS) considered the recommendations at least to be predominantly reasonable and useful and 66 % (OS) of the participants tried to implement or at least to partially implement the recommendations (IS only 33 %). Concerning the indications for the different diagnostic procedures, the results of the OS showed that hospital guidelines (44 %) and patient age (32 %) were the most frequent indications for a preoperative ECG. Hospital guidelines (40 %) and own judgement (39 %) were the most common indications for a preoperative chest x-ray and patient age still accounted for 18 % of the indications. In contrast, echocardiography (67 %), spirometry (61 %) and extended cardiac diagnostics (70 %) were primarily indicated based on own judgement. However, reasons given in this context were frequently (77 %) not in agreement with the recommendations. Comparing the results of the OS to those of the IS with respect to the indications of the different diagnostic procedures for the common case scenarios showed a varying degree of consistency with the recommendations. In both cases responses to the IS concerning the indications for the different diagnostic procedures were mostly in accordance with the recommendations compared to answers obtained in the OS. Indications for the chest x-ray showed the worst degree of consistency with the recommendations. CONCLUSIONS: Corresponding to the high significance of local standards for the decision of indicating preoperative diagnostic procedures, the development of local standards that are in agreement with the recommendations seems to be a reasonable way to facilitate the implementation of the recommendations.
  Der Anaesthesist 05/2013;
• Article: [Transversus abdominis plane block : Anesthesia procedure for abdominal wall surgery only.]

  S Schönfeld
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  ABSTRACT: The transversus abdominis plane (TAP) block is a well known method for postoperative pain control after abdominal surgery. From an anatomical and physiological point of view it should be possible to perform abdominal wall surgery, e.g. wound debridement, using a TAP block only. To the authors knowledge no studies have been published with respect to the use of TAP only. This article presents a case report demonstrating that it is possible to perform three consecutive operation procedures within 7 days using only a bilateral TAP catheter technique. The TAP block without any co-medication provides high patient comfort and should be recognized as a good alternative for abdominal wall surgery.
  Der Anaesthesist 05/2013;
• Article: [Assessment of prehospital injury severity in children : Challenge for emergency physicians.]

  M Muhm, T Danko, H Winkler, T Ruffing
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  ABSTRACT: BACKGROUND: The prognosis of polytraumatized patients is dependent on the quality of emergency room (ER) management and a smooth transition from prehospital to ER therapy is essential. The accurate assessment of prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. It also helps to ensure that medical resources are immediately available. Overestimation of injury severity wastes resources and underestimation puts patients at risk. The assessment of prehospital injury severity in adults is unreliable. In children, the assessment of injury severity seems to be even more challenging. MATERIALS AND METHODS: For the comparison of the prehospital documented injury severity and injury severity diagnosed after the ER phase, the injury severity score (ISS) and trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the revised trauma score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the abbreviated injury scale (AIS). The concordance of the injury severity within different tolerances was evaluated. A tolerance of the prehospital documented injury severity of more than ± 25 % to the injury severity calculated after ER diagnostics was considered as overestimation or underestimation. The concordance of the prehospital documented diagnosed injury severity and the severity diagnosed after the ER phase of different body regions according to the AIS was evaluated. The documented mechanism of injury in the emergency physician protocol was judged as being detailed, satisfactory or poor. RESULTS: The results showed that 69 % of the children reached the ER during on-call hours. Furthermore 92 % of the children reached the ER during the daytime between 08.00 h and 20.00 h. The transportation of 25 % of the children was on a private basis. The mean ER-ISS was 10 points (range 1-57). In 42 % of cases the ISS of the emergency physician protocol within a tolerance of ± 25 % was concordant with the ER-ISS. According to this criterion in 38 % of cases an overestimation of the assessment of the injury severity of the emergency physician was found and in 20 % an underestimation. Within a tolerance of ± 75 % based on the ER-ISS, the ISS of the emergency physician protocol was concordant in more than half of the cases (52 %). Using the TRISS with a tolerance of ± 25 % a concordance was observed in 46 % of the cases. Within a tolerance of ± 50 % based on the ER-ISS the ISS calculated after ER diagnostics was concordant in 50 % of the cases. A high concordance of the prehospital and hospital injury severity was found in the region of the face (75 %). The concordance in the body regions of the head, thorax, extremities and pelvis and soft tissue ranged between 43 % and 50 % of the cases. Of the children 38 % suffered a traffic accident, 52 % a fall of less than 3 m and 10 % of more than 3 m. The mechanism of injury was documented in detail in 70 % and satisfactory in 8 %. CONCLUSIONS: The assessment of prehospital injury severity in children is unreliable. In order to evaluate injury severity the use of anatomical trauma scores alone is insufficient. The adequate documentation of the mechanism of injury implies that the mechanism of injury seems to play a relevant role in the assessment of prehospital injury severity. The unreliable assessment of the injury severity, the arrival in the ER in on-call hours and the private transport to the hospital is a challenge to the ER leader in trauma life support for children.
  Der Anaesthesist 05/2013;
• Article: [Anesthesiological considerations for patients with trisomy 21 (Down syndrome).]

  K Ihringer, N Russ, A Walther, J-H Schiff
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  ABSTRACT: The most common chromosomal abnormality is trisomy 21 which is also known as Down syndrome and occurs in approximately 1 in 800 births. The majority of the resulting disabling conditions cannot be cured and affect people of all ages, ethnicity and economic levels. Life expectancy has increased with advances in medical care in the same way as in the rest of the population. One of the major tasks for health care professionals is to help these differently abled children and their families function in the most effective way possible as they learn to accept the limitations imposed by a persistent disability. Signs and symptoms of trisomy 21 are very variable based on the trias of mental retardation to a variable degree, hand anomalies and cardiac complications. Other abnormalities are atlantoaxial instability (AAI), tracheal stenosis, a predisposition to respiratory complications, chronic hypothyroidism, microgenia and macroglossia. These conditions are relevant to anesthetic procedures and patients with Down syndrome and their families have specific expectations and attitudes towards medical and anesthetic treatment.
  Der Anaesthesist 05/2013;
• Article: [Peripartum cardiomyopathy : Diagnostic and therapeutic challenge.]

  T Weig
  Der Anaesthesist 05/2013;
• Article: [Peripartum cardiomyopathy : Interdisciplinary challenge.]

  B Löser, S Tank, G Hillebrand, B Goldmann, W Diehl, D Biermann, J Schirmer, D A Reuter
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  ABSTRACT: Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.
  Der Anaesthesist 04/2013;
• Article: [Mass casualty incidents : Preparedness of German soccer arenas.]

  T Luiz, T Preisegger, C Madler
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  ABSTRACT: BACKGROUND: Each weekend soccer arenas attract hundreds of thousands of spectators with the German Bundesliga being one of the most attractive sport series worldwide. In 2006 when the FIFA soccer World Cup™ took place in Germany, the precautions in the participating arenas against mass casualty incidents (MCI) reached a level formerly unknown in Germany. However, it is unknown how soccer arenas are prepared to deal with such incidents in everyday life. METHODS: In 2011 all German major soccer league clubs were questioned about medical precautions in case of MCIs occurring in the stadium. The questionnaire included the following items: stadium capacity, the number of paramedic personnel, emergency physicians and ambulance vehicles, the command and communication structures, the availability of MCI plans, recent MCI drills and the frequency of MCI. RESULTS: Out of 39, 15 (38.4 %) participated, 50 % from the first league and 20.8 % from the second league. The mean stadium capacity was 41,800 spectators (minimum 10,600, maximum 80,700). Depending on the number of spectators and the individual risk score of the match the following resources were available within the stadiums (average, minimum, maximum,): emergency medical technicians 61-67 (15, 120), emergency physicians 2.3-2.5 (1, 5) and transport capacity 5.3-5.8 patients (1, 15). In 14 arenas (93.3 %) the medical personnel were trained in mass casualty care and had prepared MCI operation schedules. All stadiums had mission control centers equipped with a variety of wired and wireless communication tools, although only eight (52.3 %) arenas used a joint command structure and five (33.3 %) arenas reported MCIs (defined as a scenario involving more than 10 patients) within the past 10 years. In 40 % of the participants the last MCI-related exercise was conducted more than 36 months ago. CONCLUSIONS: Most of the participating arenas were adequately staffed to manage the first phase of MCIs but in contrast command structures and transport capacities often focused on individual emergencies. Although most of the participants stated that they planned the resources provision according to well established algorithms, the resources actually available at the arenas varied considerably. The frequency of MCIs in soccer arenas was surprisingly high in contrast to the frequency of MCI-related drills.
  Der Anaesthesist 04/2013;
• Article: [Anesthesia for electroconvulsive therapy.]

  U Grundmann, S O Schneider
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  ABSTRACT: Electroconvulsive therapy is a well-established form of treatment for a broad spectrum of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed with the patient under anesthesia and muscle relaxation. Therefore, sufficient knowledge of the physiological and pharmacological characteristics is an essential requirement for safe anesthesia. The following review is intended to provide some new aspects of the procedure and management of anesthesia.
  Der Anaesthesist 04/2013;
• Article: [Subdural hematoma after dural puncture : Fateful complication of epidural anesthesia.]

  M Schott, A Gehrke, M Gaab, J-P Jantzen
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  ABSTRACT: Subdural hematoma may occur as rare, although intervention- specific complications of accidental dural puncture by neuroaxial block. Bleeding may be caused by rapid cerebrospinal fluid loss related to traction on fragile intracranial bridging veins. This article reports a case of postdural puncture headache in a 43-year-old woman after accidental dural puncture during attempted placement of an epidural catheter for induction of abortion. Bed rest, analgesics, theophylline and hydration were to no avail and only a blood patch improved the headaches. The patient presented 7 weeks later with headache and left-sided hemiplegia. Magnetic resonance imaging showed a right frontoparietal subdural intracranial hematoma which had to be surgically evacuated. The patient recovered completely. Intracranial hematoma is a rare but serious complication of central neuroaxial block. According to current German jurisdiction this risk must be addressed when informed consent is obtained. Intracranial hematoma should be considered in the differential diagnosis of atypical headache and neurological signs (e.g. focal motor and sensory deficits and seizures) following neuroaxial block and adequate image diagnostics should be carried out without delay.
  Der Anaesthesist 04/2013;
• Article: [Disorders of serum sodium in emergency patients : Salt in the soup of emergency medicine.]

  G Lindner, A K Exadaktylos
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  ABSTRACT: Electrolyte disorders are common and potentially fatal laboratory findings in emergency patients. Approximately 20 % of patients in the emergency department present with either hyponatremia or hypernatremia. Recently it was shown that disorders of serum sodium are not only an expression of the severity of the underlying disease but independent predictors for the outcome of patients. They directly influence patient daily life by causing not only gait and concentration disturbances but also an increased tendency to fall together with a reduced bone mass. Given these new data it is even more important to detect and adequately correct dysnatremia in patients in the emergency department. Acute, symptomatic dysnatremia should be corrected promptly by use of 3 % NaCl for hyponatremia and 5 % glucose for hypernatremia. A close monitoring of serum sodium concentration is, however, essential in any case of correction of hyponatremia or hypernatremia in order to avoid rapid overcorrection and subsequent complications. A profound knowledge of the mechanisms underlying the development of hyponatremia, e.g. diuretics, syndrome of inappropriate antidiuretic hormone secretion (SIADH), heart failure and cirrhosis of the liver and hypernatremia, e.g. dehydration, infusions, diuretics and osmotic diuresis is essential. The present article describes the epidemiology, etiology and correction of hyponatremia and hypernatremia on the basis of current knowledge with special emphasis on emergency department patients.
  Der Anaesthesist 04/2013;
• Article: [Quality of results of therapy of acute respiratory failure : Changes over a period of two decades.]

  I Briegel, M Dolch, M Irlbeck, D Hauer, I Kaufmann, G Schelling
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  ABSTRACT: Progress in intensive care (ICU) treatment of acute respiratory distress syndrome (ARDS) over the last 20 years includes the introduction of extracorporeal membrane oxygenation (ECMO) for CO2 removal and the widespread use of evidence-based lung-protective ventilatory strategies. Little is known, however, about whether these changes have resulted in improvements in short-term and long-term outcome of acute respiratory distress syndrome (ARDS) within the two decades after introduction. In a retrospective study 167 long-term survivors of severe ARDS who were transferred to the clinic for anesthesiology of the University of Munich, Campus Großhadern by means of specialized intensive care unit (ICU) transport teams and treated over a period of 20 years (1985-2005) were evaluated to investigate whether significant improvements in outcome as a consequence of the above mentioned progress in ARDS therapy have occurred. The ARDS patient cohort studied was characterized with regard to demographic variables, initial acute physiology and chronic health evaluation (APACHE) II score, duration of ICU treatment, the duration of mechanical ventilation and mortality. Data on long-term outcome were collected in a subcohort (n = 125) of patients who responded to mailed questionnaires and included health-related quality of life (HRQL, SF-36 questionnaire), symptoms of post-traumatic stress disorder (PTSD), traumatic memories from ICU treatment (PTSS-10 instrument) and current state of employment. During the observation period no significant changes regarding patient age (39 ± 16 years, mean ± SD), disease severity on admission to the ICU (APACHE II scores 22 ± 5), duration of ICU treatment (47 ± 39 days) or duration of mechanical ventilation (39 ± 38 days) were found. Overall ICU mortality during the two decades was 37.3 % (range 25.0 %-38.1 %) between 1995 and 2001 and a non-significant increase in values between 36.8 % and 58.3 % during the time interval from 2002 und 2005. The paO2/FIO2-ratio on ICU admittance improved significantly between 1990 and 2000 (69 ± 5 between 1990 and 1994 versus 101 ± 12 between 1995 and 2000, p < 0.01) and remained nearly unchanged thereafter. Long-term outcome was evaluated on average 5.0 ± 3.1 years after discharge from the ICU. During the time period between 1985 and 1994 survivors of ARDS showed significant impairments in all 8 categories of the SF-36 HRQL instrument when compared to an age and sex-matched normal population with maximal differences regarding physical function (z = - 1.01), general health perception (z = - 1.17) and mental health (z = - 1.3). Patients who were treated from 1995 to 2005 were still impaired in 7 out of 8 categories of HRQL but reported significantly better mental health (49.6 ± 16.5 vs. 68.6 ± 17.8, p < 0,01) and better physical function than individuals from the previous decade (49.6 ± 16.5 vs. 73.4 ± 27.5, p = 0,03). The difference of mental health was no longer significant when compared to a healthy age and sex matched control group (p = 0.14) but the difference in physical function still was (z = - 0.48, p < 0.01). The incidence of severe post-traumatic stress defined as a PTSS-10 score ≥ 35 was 20.4 % and remained unchanged throughout the 2 decades of observation. The PTSS-10 scores correlated with the number of traumatic memories present (r = 0.43, p < 0.01, n = 125). More than 50 % of long-term survivors were able to return to full time work with no significant changes during the 2 decades of observation. The introduction of new modalities of ARDS treatment were associated with higher paO2/FIO2-ratios on ICU admittance but had no effect on short-term outcomes including duration of ICU therapy, mechanical ventilation or mortality. The ARDS patients are still at risk for post-traumatic stress and persistent impairments in HRQL. Apart from some improvements in HRQL, the outcome of ARDS therapy remained largely unchanged during two decades.
  Der Anaesthesist 04/2013;
• Article: [Transfusion-related acute lung injury.]

  S Tank, A Sputtek, R Kiefmann
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  ABSTRACT: Transfusion-related acute lung injury (TRALI) developed into the leading cause of transfusion-related morbidity and mortality after the first description by Popovsky et al. approximately three decades ago. It was the most frequent reason for transfusion-related fatalities worldwide before implementation of risk minimization strategies by donor selection. Plasma-rich blood products, such as fresh frozen plasma and apheresis platelets seem to be the leading triggers of TRALI. Hypoxemia and development of pulmonary edema within 6 h of transfusion are the diagnostic criteria for TRALI. The differentiation between cardiac failure and other transfusion-related lung injuries, such astransfusion-associated circulatory overload ( TACO) is difficult and causal treatment is not available. Therapy is based on supportive measures, such as oxygen insufflationor mechanical ventilation. The exactly pathogenesis is still unknown but the most propagated hypothesis is the two-event-model. Neutrophils are primed by the underlying condition, e.g. sepsis or trauma during the first event and these primed neutrophils are activated by transfused leukoagglutinating antibodies (immunogen) or bioreactive mediators (non-immunogen) during the second-event. Transfusion of leukoagglutinating antibodies from female donors with one or more previous pregnancies is the most frequent reason. No more TRALI fatalities were reported after implementation of the donor selection in Germany in 2009.
  Der Anaesthesist 04/2013;
• Article: [TRAILI - A lecture for hemovigilance].

  J Biscoping
  Der Anaesthesist 04/2013; 62(4):252-3.
• Article: [Use of 2 % hyperbaric prilocaine for spinal anesthesia : Sensitivity analysis in outpatient surgery.]

  D A Vagts, C H Bley, C W Mutz
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  ABSTRACT: BACKGROUND: Hyperbaric prilocaine 2 % has been available for spinal anesthesia in Germany for 2 years and is characterized by a short duration of action, a lack of postspinal urine retention and a reduction of transient neurological syndromes. However, desirable pharmacological properties are contrasted by higher pharmacological costs compared to hyperbaric bupivacaine 0.5 %. MATERIALS AND METHODS: This paper deals with a sensitivity analysis for the use of hyperbaric prilocaine 2 % versus hyperbaric bupivacaine 0.5 % in Germany and investigates the financial break-even point up to which time a shorter patient stay in the recovery area compensates for the higher costs for the use of prilocaine 2 % for ambulatory spinal aaesthesia. A sensitivity analysis is an instrument of investment appraisal. It is a model to reduce a complex system with numerous variables to a straightforward calculation by assuming a framework requirement and systematically changing only one or two variables. In this paper additional costs for spinal anesthesia have been neglected, only the time a nurse spends with the patient in the recovery area and the costs for each vial of drug have been taken into account. RESULTS: For the assumption of 75 min time until leaving the recovery area and being discharged after spinal anesthesia with hyperbaric prilocaine 2 % versus 150 min (recovery of motor competence) or 405 min (voiding) with hyperbaric bupivacaine 0.5 % the calculation shows a cost benefit for hyperbaric prilocaine 2 % of EUR 11.64 or EUR 64.76 compared to hyperbaric bupivacaine 0.5 % and EUR 13.32 or EUR 66.44 compared to isobaric bupivacaine 0.5 %. Under the assumption that all patients who have received spinal anesthesia with hyperbaric bupivacaine 0.5 % can be discharged from the recovery area after 150 min, the use of hyperbaric prilocaine 2 % remains more economical as long as the patient is discharged from the recovery area within 130 min. If 405 min recovery time is assumed for hyperbaric bupivacaine 0.5 % the costs compared with hyperbaric prilocaine 2 % will be compensated after 300 min. To be more economical compared to patients with hyperbaric prilocaine 2 % those who received hyperbaric bupivacaine 0.5 % must be discharged from the recovery area within at least 100 min. However, a time of less than 160 min for discharge from the recovery area is not published anywhere in the literature. In summary, the use of hyperbaric prilocaine 2 % for 60 min operation time is cheaper than the use of bupivacaine 0.5 % as long as patients do not stay in the recovery area for longer than 120 min and are discharged from the recovery area. CONCLUSIONS: For German framework conditions the use of hyperbaric prilocaine 2 % can provide an economical advantage compared to the use of hyperbaric bupivacaine 0.5 % if staff assignment can be flexible.
  Der Anaesthesist 03/2013;
• Article: [Peripartum aortic dissection.]

  C Pachler, I Knez, E Petru, O Dörfler, M Vicenzi, W Toller
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  ABSTRACT: A 29-year-old primagravida developed severe chest pains during labor. An emergency caesarean section was performed as the symptoms persisted. Imaging diagnosis immediately after delivery revealed an acute proximal (type A) aortic dissection. The patient was transferred to the nearest cardiothoracic surgery centre and successful emergency surgical aortic repair was performed. The perioperative course of a type A aortic dissection during pregnancy and labor is complicated by time pressure, diagnostic restrictions until delivery and potentially fatal uterine bleeding during cardiopulmonary bypass and hypothermic cardiac arrest. This case report describes the diagnosis and the surgical, anesthesiological and gynecological management of this life-threatening peripartum complication.
  Der Anaesthesist 03/2013;