[Bacterial load of the surroundings during rigid diagnostic bronchoscopy under high frequency jet-ventilation]. / Mikrobielle Belastung der Umgebung während der Anwendung der Hochfrequenz-Jetventilation in der Bronchoskopie.

BACKGROUND: High-frequency jet ventilation (HFJV) is used in pneumological endoscopy for rigid, diagnostic, and therapeutic bronchoscopies. It is unclear to what extent the unobstructed flow of respiratory gas from the patient's lungs causes microbial contamination of the surrounding air. MATERIAL AND METHODS: After the start of the HFJV (15 min) in 16 rigid bronchoscopies, airborne pathogen measurements were taken directly at the distal endoscope outlet, at examiner height (40 cm above the endoscope outlet), at a 2 m distance from the endoscope in the room and at the supply air outlet of the examination room using an RCS air sampler. The number and type of pathogens isolated in the air samples were then determined, as well as germs in the bronchoalveolar lavage fluid (BALF) from the patient's lungs. RESULTS: An increased bacterial density (136 and 114 CFU/m3) was detected directly at the distal end of the endoscope and at examiner height at a distance of 40 cm, which decreased significantly with increasing distance from the bronchoscope (98 CFU/m3 at a distance of 2 m and 82 CFU/m3 at the supply air outlet). The most frequently detected bacteria were Staphylococcus spp., Micrococcus spp. and Bacillus spp. In the BALF, pathogens could only be cultivated in four of 16 samples, but the same pathogens were detected in the BALF and the ambient air. CONCLUSION: When performing a rigid bronchoscopy, in which patients are mechanically ventilated in a controlled manner using an open HFJV system, there is an increased pathogen load in the ambient air and therefore a potential risk for the examiner.

IL-13 determines specific IgE responses and SARS-CoV-2 immunity after mild COVID-19 and novel mRNA vaccination.

After recovery, mild and severe COVID-19 diseases are associated with long-term effects on the host immune system, such as prolonged T-cell activation or accumulation of autoantibodies. In this study, we show that mild SARS-CoV-2 infections, but not SARS-CoV-2 spike mRNA vaccinations, cause durable atopic risk factors such as a systemic Th2- and Th17-type environment as well as activation of B cells responsive of IgE against aeroallergens from house dust mite and mold. At an average of 100 days post mild SARS-CoV-2 infections, anti-mold responses were associated with low IL-13 levels and increased pro-inflammatory IL-6 titers. Acutely severely ill COVID-19 patients instead showed no evidence of atopic reactions. Considering convalescents of mild COVID-19 courses and mRNA-vaccinated individuals together, IL-13 was the predominant significantly upregulated factor, likely shaping SARS-CoV-2 immunity. Application of multiple regression analysis revealed that the IL-13 levels of both groups were determined by the Th17-type cytokines IL-17A and IL-22. Taken together, these results implicate a critical role for IL-13 in the aftermath of SARS-CoV-2 mild infections and mRNA vaccinations, conferring protection against airway directed, atopic side reactions that occur in mildly experienced COVID-19.

Long-term opioid therapy and mental health comorbidity in patients with chronic pain.

OBJECTIVES: Evidence suggests that patients with chronic pain and mental illness are more likely to receive long-term opioid therapy (LTOT) and at higher doses but are also at increased risk of experiencing opioid-related harm. This study investigates LTOT and its relationship to mental illness in the setting of a university-based outpatient pain clinic with liaison psychiatric care. METHODS: Retrospective analysis of patients with chronic pain admitted between 2011 and 2015. After a 1-year treatment period, patients with non-opioid treatment, guideline-recommended LTOT, and high-dose LTOT were compared, and multiple regression analysis was performed to identify predictors of higher opioid dosage. RESULTS: Of 769 patients, 46% received LTOT (opioids for >90 consecutive days), 13% at high dosage (>120 oral morphine milligram equivalents [MME] / day). Two thirds of all patients had mental illness. The prevalence of psychiatric diagnoses and prescription rate of psychotropic medication did not significantly differ between groups. Pain chronicity stages, use of antidepressants, and sex significantly predicted MME/day but explained only a minor part of the variance. The association with antidepressants can be attributed to the prescription of antidepressants for analgesic purposes rather than for treating depression. No association with any other type of psychiatric disorders was observed. CONCLUSION: This study shows that mental health comorbidity is highly prevalent but that the prescribed opioid dosage is independent of it in the clinical setting of this study. The concept of liaison psychiatric care might have essentially contributed to the "detachment" of opioid prescription and psychiatric conditions but cannot be isolated from other potentially contributing factors within this single-center observational study.

[Accidental Awareness during General Anaesthesia]. / Akzidentelle Wachheit während Allgemeinanästhesie.

Accidental awareness during general anaesthesia (AAGA) is a rare but severe complication. The reported incidence of AAGA may depend on the assessment of intraoperative awareness with explicit recall and there are substantial variations between subspecialties and groups of patients. The majority of prospective studies using structured interviews reported an incidence of AAGA at 0.1-0.2% during general anaesthesia, however, higher values were observed in paediatric (0.2-1.2%) and obstetric patients (0.47%). Risk factors that predispose to AAGA are patient conditions, ASA status, female gender, patient age, history of AAGA, surgical procedure, anaesthetic drug type, muscle relaxation, dosages of hypnotic or analgesic drugs, monitoring and malfunction of anaesthesia systems. Preventive strategies include careful assessment of risk factors, avoidance of underdosages of hypnotics and analgetics during general anaesthesia and monitoring of depth of anaesthesia in risk patients. The health-related consequences can be serious and psychopharmacological and psychotherapeutic interventions are indicated in patients who have experienced AAGA.

Unique autoantibody prevalence in long-term recovered SARS-CoV-2-infected individuals.

The variability in resolution of SARS-CoV-2-infections between individuals neither is comprehended, nor are the long-term immunological consequences. To assess the long-term impact of a SARS-CoV-2-infection on the immune system, we conducted a prospective study of 80 acute and former SARS-CoV-2 infected individuals and 39 unexposed donors to evaluate autoantibody responses and immune composition. Autoantibody levels against cyclic citrullinated peptide (CCP), a specific predictor for rheumatoid arthritis (RA), were significantly (p = 0.035) elevated in convalescents only, whereas both acute COVID-19 patients and long-term convalescents showed critically increased levels of anti-tissue transglutaminase (TG), a specific predictor of celiac disease (CD) (p = 0.002). Both, anti-CCP and anti-TG antibody levels were still detectable after 4-8 months post infection. Anti-TG antibodies occurred predominantly in aged patients in a context of a post-SARS-CoV-2-specific immune composition (R2 = 0.31; p = 0.044). This study shows that increased anti-CCP and anti-TG autoantibody levels can remain long-term after recovering even from mildly experienced COVID-19. The inter-relationship of the lung as viral entry side and RA- and CD-associated autoimmunity indicates that a SARS-CoV-2-infection could be a relevant environmental factor in their pathogenesis.

Effect of Global Ventilation to Perfusion Ratio, for Normal Lungs, on Desflurane and Sevoflurane Elimination Kinetics.

BACKGROUND: Kinetics of the uptake of inhaled anesthetics have been well studied, but the kinetics of elimination might be of more practical importance. The objective of the authors' study was to assess the effect of the overall ventilation/perfusion ratio (VA/Q), for normal lungs, on elimination kinetics of desflurane and sevoflurane. METHODS: The authors developed a mathematical model of inhaled anesthetic elimination that explicitly relates the terminal washout time constant to the global lung VA/Q ratio. Assumptions and results of the model were tested with experimental data from a recent study, where desflurane and sevoflurane elimination were observed for three different VA/Q conditions: normal, low, and high. RESULTS: The mathematical model predicts that the global VA/Q ratio, for normal lungs, modifies the time constant for tissue anesthetic washout throughout the entire elimination. For all three VA/Q conditions, the ratio of arterial to mixed venous anesthetic partial pressure Part/Pmv reached a constant value after 5 min of elimination, as predicted by the retention equation. The time constant corrected for incomplete lung clearance was a better predictor of late-stage kinetics than the intrinsic tissue time constant. CONCLUSIONS: In addition to the well-known role of the lungs in the early phases of inhaled anesthetic washout, the lungs play a long-overlooked role in modulating the kinetics of tissue washout during the later stages of inhaled anesthetic elimination. The VA/Q ratio influences the kinetics of desflurane and sevoflurane elimination throughout the entire elimination, with more pronounced slowing of tissue washout at lower VA/Q ratios.

Arterial and Mixed Venous Kinetics of Desflurane and Sevoflurane, Administered Simultaneously, at Three Different Global Ventilation to Perfusion Ratios in Piglets with Normal Lungs.

BACKGROUND: Previous studies have established the role of various tissue compartments in the kinetics of inhaled anesthetic uptake and elimination. The role of normal lungs in inhaled anesthetic kinetics is less understood. In juvenile pigs with normal lungs, the authors measured desflurane and sevoflurane washin and washout kinetics at three different ratios of alveolar minute ventilation to cardiac output value. The main hypothesis was that the ventilation/perfusion ratio (VA/Q) of normal lungs influences the kinetics of inhaled anesthetics. METHODS: Seven healthy pigs were anesthetized with intravenous anesthetics and mechanically ventilated. Each animal was studied under three different VA/Q conditions: normal, low, and high. For each VA/Q condition, desflurane and sevoflurane were administered at a constant, subanesthetic inspired partial pressure (0.15 volume% for sevoflurane and 0.5 volume% for desflurane) for 45 min. Pulmonary arterial and systemic arterial blood samples were collected at eight time points during uptake, and then at these same times during elimination, for measurement of desflurane and sevoflurane partial pressures. The authors also assessed the effect of VA/Q on paired differences in arterial and mixed venous partial pressures. RESULTS: For desflurane washin, the scaled arterial partial pressure differences between 5 and 0 min were 0.70 ± 0.10, 0.93 ± 0.08, and 0.82 ± 0.07 for the low, normal, and high VA/Q conditions (means, 95% CI). Equivalent measurements for sevoflurane were 0.55 ± 0.06, 0.77 ± 0.04, and 0.75 ± 0.08. For desflurane washout, the scaled arterial partial pressure differences between 0 and 5 min were 0.76 ± 0.04, 0.88 ± 0.02, and 0.92 ± 0.01 for the low, normal, and high VA/Q conditions. Equivalent measurements for sevoflurane were 0.79 ± 0.05, 0.85 ± 0.03, and 0.90 ± 0.03. CONCLUSIONS: Kinetics of inhaled anesthetic washin and washout are substantially altered by changes in the global VA/Q ratio for normal lungs.

[Drug Interactions in Emergency Medicine]. / Arzneimittelinteraktionen in der Notfallmedizin.

Unwanted drug interactions are responsible for a high rate of hospitalization. The rate of unwanted interactions increases with the number of drugs taken. Drug interactions occur on pharmacodynamic and pharmacokinetic levels. They can be caused by an emergency treatment and can be the cause of a necessary emergency treatment. To avoid unwanted drug interactions, electronic databases and smartphone apps could be helpful.

Rational application of antibiotics-The influence of anaesthetists' gender on self-confidence and knowledge.

BACKGROUND: High rates of multiresistant pathogens require detailed knowledge about rational utilization of antibiotics. Many physicians consider themselves uncertain about the interpretation of microbiological diagnostics. We examined whether self-confidence, self-rated knowledge, and objective knowledge regarding the use of antibiotics are associated with gender. METHODS: For this survey study, in 2017, anaesthesiologists and residents of 16 anaesthetic departments in Germany were asked to complete the Multiinstitutional Reconnaissance of practice with Multiresistant bacteria (MR2) survey. It consists of 55 items evaluating self-confidence regarding the practical use of antibiotics (n = 6), self-rated theoretical knowledge (n = 16), and objective knowledge (n = 5). Their answers to these items in relation to their gender were analysed using Chi-square, Kruskal-Wallis-H-Tests, and unadjusted as well as adjusted logistic regression models. RESULTS: Six hundred eighty-four (response rate: 53.9 %) questionnaires were returned and were available for analysis. Female doctors (35.5 %) felt less self-confident (P < 0.001). Self-rated knowledge differed in overall mean (P = 0.014) and the unadjusted (odds ratio [OR]: 0.55; P = 0.013) but not in the adjusted logistic regression (OR: 0.84; P = 0.525). Objective knowledge differed after pooling questions (61.2% correct answers vs 65.4%, P = 0.01) but not with respect to single items and the adjusted logistic regression (OR: 0.83, P = 0.356). CONCLUSION: Less self-confidence and a lower self-rated knowledge were found in female anaesthetists; this is consistent to the gender phenomena observed by other researchers. Nevertheless, between the 2 groups objective knowledge did not differ significantly in any item.

[Violence in the Emergency Medicine (Emergency Rescue Service and Emergency Departments) - Current Situation in Germany]. / Gewalt in der Notfallmedizin ­ gegenwärtiger Stand in Deutschland.

BACKGROUND: During the last years healthcare personnel is more often faced with different degrees of violence and aggression while doing their jobs. However, systematic data with respect to offender profiles, reasons, frequency and types of violence in emergency medicine in Germany has not been systematically analyzed. AIM: The aim of this article is to overview the data of present German studies. RESULTS: Only a few German studies could be included. Data suggest that violence in emergency medicine is an underreported but ubiquitous, persistent problem. 90% of the participants in the surveyed rescue staff and 75% of the participants in the surveyed emergency departments had experienced occasional verbal or physical violence within the last months before survey started. Most participants felt poorly prepared to react on aggressive situations. There is a need for appropriate training in de-escalation skills and self defence. Moreover a constant presence of security services was demanded to reduce violence in emergency departments.

Independent Predictors for Higher Postoperative Pain Intensity During Recovery After Open Thoracic Surgery: A Retrospective Analysis in 621 Patients.

Objective: To evaluate two standard procedure-specific pain regimens and to assess independent predictors for higher pain intensity after thoracic surgery. Methods: Patients received either oral opioid analgesia (Opioid Group) or epidural analgesia and were then bridged to systemic opioid analgesia (EDA + O Group) in this retrospective observational study. Medical history, discharge letters, anesthetic protocols, and pain protocols were evaluated in 621 patients after open thoracotomy and assessed with a stepward back elimination in a multivariate logistic regression model. Results: Data of 621 thoracotomies in 2014 were analyzed, 309 patients in the Opioid Group and 312 patients in the EDA + O Group. Pain scores at rest and on coughing were significantly lower in the EDA + O Group on postoperative days (PODs) 1-4 (P < 0.001). Stepwise backward elimination in multivariate logistic regression identified preexisting pain disease (P = 0.034), no epidural analgesia (P < 0.001), opioids in preoperative pain therapy (P < 0.001), and antidepressant medication (P = 0.003) as independent risk factors for higher pain intensity at rest on PODs 1-4. Same on PODs 5-8 with regard to opioids in preoperative pain therapy (P < 0.001) and antidepressant medication (P = 0.018). Moreover, on PODs 5-8, male gender had a lower risk (P < 0.003) for pain, and preexisting musculosceletal disease had a lower risk for more postoperative pain (P = 0.009). On coughing, male gender and younger age proved to have a lower risk for postoperative pain on PODs 1-8 and on PODs 1-4, respectively. Opioids in preexisting pain therapy and antidepressant medication were identified as risk factors for pain on PODs 1-8 on coughing, and pain disease was identified as a risk factor for more pain on PODs 1-4 (P = 0.041). Moreover, preexisting cardiac disease indicated more pain on PODs 1-4 (P = 0.05), and musculoskeletal disease and neurological disease indicated more pain on PODs 5-8 (P = 0.041, and P = 0.023). Conclusions: We present data on independent risk factors for higher pain intensity during recovery after thoracotomy. The lack of postoperative epidural analgesia, female gender, preexisting opioid pain therapy, and chronic pain are the strongest risk factors for higher pain intensity. Antidepressant medication was identified as an independent risk factor at rest and on coughing on all PODs. Study limitations: The study design is retrospective.

[Use of Bronchial Blockers for Lung Isolation]. / Atemwegsmanagement in der Thoraxanästhesie mit dem Bronchusblocker.

Traditionally the double-lumen-tube (DLT) is considered the gold standard for lung separation. Despite being equally feasible for standard situations, there are special populations and circumstances requiring the use of a bronchial blocker (BB) to establish one-lung ventilation. Children under 8 years of age and patients without a patent orotracheal airway necessitate the use of a bronchial blocker in most cases, as well as those requiring selective lobar blockade or a rapid sequence induction. Surgery with predicted postoperative mechanical ventilation or in tracheotomized patients at least favors their use by avoiding the complications of a tube exchange. Bronchial blocker models currently in clinical use include the wire-guided Arndt-Blocker, the Flexitip Cohen-Blocker, the Fuji Uniblocker, the Y-shaped EZ-Blocker and the tracheoscopy-guided VivaSight-EB. Their common concept is the occlusion of the operative lung by the inflation of their distal balloon, with the deflation of that lung occurring through their inner lumen. They mainly differ in their mode of placement. Bronchial blockers offer a clinical performance comparable to the DLT. Placement times for lung isolation devices and surgical exposure may depend more on the experience of the anaesthetist than the device itself. Bronchial blockers won't replace the DLT as gold standard at least due to their cost of acquisition, but provided adequate training outside of the emergency situation, their utilisation offers equal operative conditions at comparable placement times, dislocation rates and ease of use. A modern bronchial blocker should be available in institutions managing complex thoracic cases.

Effect of Bronchoconstriction-induced Ventilation-Perfusion Mismatch on Uptake and Elimination of Isoflurane and Desflurane.

BACKGROUND: Increasing numbers of patients with obstructive lung diseases need anesthesia for surgery. These conditions are associated with pulmonary ventilation/perfusion (VA/Q) mismatch affecting kinetics of volatile anesthetics. Pure shunt might delay uptake of less soluble anesthetic agents but other forms of VA/Q scatter have not yet been examined. Volatile anesthetics with higher blood solubility would be less affected by VA/Q mismatch. We therefore compared uptake and elimination of higher soluble isoflurane and less soluble desflurane in a piglet model. METHODS: Juvenile piglets (26.7 ± 1.5 kg) received either isoflurane (n = 7) or desflurane (n = 7). Arterial and mixed venous blood samples were obtained during wash-in and wash-out of volatile anesthetics before and during bronchoconstriction by methacholine inhalation (100 µg/ml). Total uptake and elimination were calculated based on partial pressure measurements by micropore membrane inlet mass spectrometry and literature-derived partition coefficients and assumed end-expired to arterial gradients to be negligible. VA/Q distribution was assessed by the multiple inert gas elimination technique. RESULTS: Before methacholine inhalation, isoflurane arterial partial pressures reached 90% of final plateau within 16 min and decreased to 10% after 28 min. By methacholine nebulization, arterial uptake and elimination delayed to 35 and 44 min. Desflurane needed 4 min during wash-in and 6 min during wash-out, but with bronchoconstriction 90% of both uptake and elimination was reached within 15 min. CONCLUSIONS: Inhaled methacholine induced bronchoconstriction and inhomogeneous VA/Q distribution. Solubility of inhalational anesthetics significantly influenced pharmacokinetics: higher soluble isoflurane is less affected than fairly insoluble desflurane, indicating different uptake and elimination during bronchoconstriction.

Robotic thoracic surgery results in shorter hospital stay and lower postoperative pain compared to open thoracotomy: a matched pairs analysis.

BACKGROUND: To evaluate postoperative pain intensity and length of hospital stay after open or robotic thoracic surgery in a standardized postoperative pain therapy setting. METHODS: In the present retrospective (oberservation period: January 2015 until January 2016) study we matched data of 38 patients with robotic thoracic surgery ("robotic patients"; age: 62.2 years, male gender: 42.1%) with 38 patients with open thoracic surgery ("open patients"; age: 62.5 years, male gender: 42.1%). Power analysis indicated that 36 patients per group would be required. RESULTS: 68% of all patients received an epidural catheter, and 32% a systemic opioid based analgesia. Postoperative pain intensity in "robotic patients" was lower at rest on postoperative day 3-5 compared to "open patients" (NRS POD 3 robotic surgery 0.5±1.0 vs. open surgery 1.0±1.6, p = 0.04; NRS POD 4 robotic surgery 0,5 ± 1.0 vs. open surgery 1.1±1.3, p=0.04; NRS POD 5 robotic surgery 0.7 ± 1.0 vs. open surgery 1.5±1.5, p=0.003). Chest tube duration was shorter in "robotic patients" (2.9 ± 2.0 days vs. 4.9 ± 2.2 days; p < 0.001). Moreover, length of hospital stay was shorter in "robotic patients" than in "open patients" (6.9 days vs. 8.0 days; p = 0.02). There was no significant difference in postoperative opioid consumption between the groups. Nearly 95% of patients were discharged home with an oral opioid in both groups. CONCLUSION: Patients after robotic pulmonary resection experience lower postoperative pain and are discharged earlier from hospital than patients after open thoracic surgery. STUDY LIMITATIONS: The study design is retrospectively.

[Thoracic Trauma - Prehospital Treatment]. / Der Patient mit Thoraxtrauma: präklinische Versorgung.

Penetrating thoracic injuries are rare in Germany and common in urban regions. 10 percent of the patients in Emergency Departments suffer from blunt thoracic trauma. Mechanism of trauma can predict the severity of the injuries. Very fast life-threatening injuries with hemodynamic problems like tension pneumothorax or cardiac tamponade have to be diagnosed. Prehospital emergency physicians need skills in ultrasound for diagnosis and in invasive therapy like chest tube or pericardium drainage tube. The application of an algorithm in exploration of a thoracic trauma seems to be useful. The selection of trauma center depends on the severity of the trauma, if necessary with the availability of extracorporeal circulation.

[Anesthetic Management in Thoracic Trauma Patients]. / Der Patient mit Thoraxtrauma: anästhesiologisches Management.

In daily practice, management of patients with blunt thoracic trauma is challenging for the anesthetist. Injuries of airways, lungs, diaphragm, heart and large vessels are the main difficulties.Respiratory and circulatory physiology in general is affected by general anesthesia, which may result in an increased number of perioperative complications. Therefore, anesthetic management of patients with thoracic trauma needs to address different clinical topics: management of difficult airways, intrinsic effects of anesthetics and mechanical ventilation on respiratory and cardiac function, the adequate replacement of blood loss as well as type and extent of the surgical intervention. Postoperatively, sufficient pain therapy avoids pulmonary complications and can improve outcome.Therefore, a high degree of (patho-)physiological understanding and manual skills are required in this scenario. Interdisciplinary cooperation during diagnostic, treatment and in the perioperative course is a prerequisite for a successful management.The present work describes the main characteristics of thoracic trauma and discusses important precautions and typical problems the anesthetist has to face in the clinical setting.

Post-thoracotomy dysrhythmia.

PURPOSE OF REVIEW: This article reviews and summarizes the pathophysiology, risk factors, and the management of arrhythmias in patients undergoing noncardiac thoracic surgery. RECENT FINDINGS: Cardiac arrhythmias are common findings in the perioperative period, particularly with increasing age. They often complicate the course of the patient's recovery after operation. The most common postoperative arrhythmia is atrial fibrillation. It requires either a rate or rhythm control strategy, and the need for anticoagulation has to be assessed depending on the duration of the arrhythmia and risk factors. Fortunately, malign sustained ventricular tachyarrhythmias (ventricular tachycardia, ventricular fibrillation) are rare. Acute treatment and, in the absence of a reversible cause, a long-term preventive strategy may be warranted. Transient bradyarrhythmias can be managed by atropine or with temporary pacing. SUMMARY: Arrhythmias are common after thoracotomy. Physicians treating patients with postoperative arrhythmias should bear in mind that arrhythmia management does not only comprise a specific therapy for the arrhythmia itself, but also includes the correction of transient and correctable predisposing and causative factors.