Dynamic parameters of fluid responsiveness in the operating room : An analysis of intraoperative ventilation framework conditions.

BACKGROUND: Reliable assessment of fluid responsiveness with pulse pressure variation (PPV) depends on certain ventilation-related preconditions; however, some of these requirements are in contrast with recommendations for protective ventilation. OBJECTIVE: The aim of this study was to evaluate the applicability of PPV in patients undergoing non-cardiac surgery by retrospectively analyzing intraoperative ventilation data. MATERIAL AND METHODS: Intraoperative ventilation data from three large medical centers in Germany and Switzerland from January to December 2018 were extracted from electronic patient records and pseudonymized; 10,334 complete data sets were analyzed with respect to the ventilation parameters set as well as demographic and medical data. RESULTS: In 6.3% of the 3398 included anesthesia records, patients were ventilated with mean tidal volumes (mTV) > 8 ml/kg predicted body weight (PBW). These would qualify for PPV-based hemodynamic assessment, but the majority were ventilated with lower mTVs. In patients who underwent abdominal surgery (75.5% of analyzed cases), mTVs > 8 ml/kg PBW were used in 5.5% of cases, which did not differ between laparoscopic (44.9%) and open (55.1%) approaches. Other obstacles to the use of PPV, such as elevated positive end-expiratory pressure (PEEP) or increased respiratory rate, were also identified. Of all the cases 6.0% were ventilated with a mTV of > 8 ml/kg PBW and a PEEP of 5-10 cmH2O and 0.3% were ventilated with a mTV > 8 ml/kg PBW and a PEEP of > 10 cmH2O. CONCLUSION: The data suggest that only few patients meet the currently defined TV (of > 8 ml/kg PBW) for assessment of fluid responsiveness using PPV during surgery.

International survey of neurosurgical anesthesia (iSonata) : An international survey of current practices in neurosurgical anesthesia.

BACKGROUND: No standardized recommendations have been currently defined for anesthesia management of patients undergoing elective intracranial surgery. It can therefore be assumed that international clinical institutions have diverging approaches or standard operating procedures (SOP) which determine the type of general anesthesia, hemodynamic management, neuromuscular blockade, implementation of hypothermia and postoperative patient care. OBJECTIVE: This international survey aimed to assess perioperative patient management during elective intracranial procedures. This survey was performed from February to October 2018 and 311 neurosurgical, maximum care centers across 19 European countries were contacted. The aim was to evaluate the anesthesia management to provide relevant data of neuroanesthesia practices across European centers. The survey differentiated between vascular and non-vascular as well as supratentorial and infratentorial procedures. RESULTS: A total of 109 (35.0%) completed questionnaires from 15 European countries were analyzed. The results illustrated that total intravenous anesthesia was most commonly implemented during elective intracranial procedures (83.8%). All centers performed endotracheal intubation prior to major intracranial surgery (100%). Central venous lines were placed in 63.3% of cases. Moderate intraoperative hypothermia was carried out in 12.8% of the procedures, especially during vascular supratentorial and infratentorial surgery. A neuromuscular blockade during surgery was implemented in 74.1% of patients. Assessment of the neuromuscular junction was performed in 59.2% of cases, 76.7% of patients were immediately extubated in the operating room. 84.7% of these patients were directly transferred to a monitoring ward or an intensive care unit (ICU) and 55.1% of ventilated patients were transferred directly to an ICU. CONCLUSION: The data demonstrate that many aspects of anesthesia management during elective intracranial surgery vary between European institutions. The data also suggest that a broad consensus exists regarding the implementation of total intravenous anesthesia, airway management (endotracheal intubation), the implementation of urinary catheters, large bore peripheral venous lines and the broad availability of cross-matched red blood cell concentrates. Nevertheless, anesthesia management (e.g. central venous catheterization, moderate hypothermia, neuromuscular monitoring) is still handled differently across many European institutions. A lack of standardized guidelines defining anesthetic management in patients undergoing intracranial procedures could explain this variability. Further studies could help establish optimal anesthesia management for these patients. This in turn could help in the development of national and international guidelines and SOPs which could define optimal management strategies for intracranial procedures.

[Anesthesia in gastrointestinal endoscopy: peroral endoscopic myotomy]. / Anästhesie in der gastrointestinalen Endoskopie: perorale endoskopische Myotomie.

Idiopathic achalasia is a motility disorder of the esophagus characterized by a dysfunction of the lower esophageal sphincter, which typically manifests as dysphagia. Peroral endoscopic myotomy (POEM) is an interventional endoscopic procedure for achalasia, which was introduced in 2010. Although results from randomized studies comparing short-term and long-term safety and efficacy are yet to be published, POEM is regarded to be less invasive than the standard treatment of achalasia (laparoscopic Heller myotomy). POEM is the first endoscopic procedure routinely performed with the patient under general anesthesia. During the preoperative assessment particular attention must be paid to the specific fasting intervals and the risk of aspiration during induction of anesthesia. For the purpose of temporary surgical access, the integrity of the esophageal wall is deliberately interrupted to create a long submucosal tunnel. As a result, unwanted fistulas can arise between the esophageal lumen, the mediastinum, the pleura or the intraperitoneal cavity. Endoscopically insufflated CO2 may escape into these surrounding compartments with subsequent systemic CO2 accumulation, capnomediastinum, tension capnoperitoneum or pneumothorax. As a result substantial cardiorespiratory instability can arise. Thus, the attending anesthesiologist must be familiar with these typical complications and with specific emergency measures, such as compensatory hyperventilation, percutaneous needle decompression and thoracic drainage. The POEM procedure is a therapeutic innovation and interdisciplinary challenge. However, anesthesia standards of care have not yet been specified. The aim of this review is therefore to outline some clinical recommendations for the daily clinical practice based on existing evidence.

[2018 update ESC/ESH guidelines on management of arterial hypertension : What is important for anesthesiologists?] / 2018 Update ESC/ESH-Leitlinie "Management der arteriellen Hypertonie" : Was ist für den Anästhesiologen wichtig?

In 2018 the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) published an update of the guidelines for the management of arterial hypertension from 2013. The guidelines feature several altered and partially new recommendations for the diagnostics and treatment of arterial hypertension. Anesthesiology is an interdisciplinary field that is closely related to internal medicine and cardiology. Anesthesiologists should therefore be aware and informed about important changes in these guidelines. This article highlights the most important innovations in the ESC/ESH guidelines 2018 on management of arterial hypertension.

[ESC guidelines 2018 on myocardial revascularization : What must anesthesiologists know?] / ESC-Leitlinie 2018 "Myokardiale Revaskularisation" : Was muss der Anästhesiologe wissen?

In 2018 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published an update of the guidelines on myocardial revascularization from 2014. In these updated guidelines both associations agreed on joint recommendations concerning myocardial revascularization. Especially anesthesiologists being part of the cardiac anesthesia or heart team and intensive care physicians should have knowledge about the new or changed recommendations of these guidelines. This article summarizes the most important changes of the ESC/EACTS guidelines on myocardial revascularization.

[Uvular edema. Rare complication in anesthesia]. / Uvula-Ödem. Seltene anästhesiologische Komplikation.

A uvular edema can be associated with angioedema, urticaria and anaphylaxis. Furthermore, it can be caused by medications, such as angiotensin-converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs and angiotensin II receptor antagonists. Other reasons can be cannabis or cocaine use or a traumatic irritation of the uvula. This article presents the case of a patient who underwent kidney transplantation and developed extensive edema of the uvula that occurred postoperatively after general anaesthesia. The case report describes the diagnosis and therapy of this rare disease.

[Peripartum cardiomyopathy: interdisciplinary challenge]. / Peripartale Kardiomyopathie: Interdisziplinäre Herausforderung.

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.

Sesquiterpene lactones as inhibitors of human neutrophil elastase.

Human neutrophil elastase (HNE) is a serine protease that has been implicated in the abnormal turnover of connective tissue proteins and has been described as an important pathogenic factor in several inflammatory diseases such as rheumatoid arthritis or cystic fibrosis. Here we investigated 17 sesquiterpene lactones (SLs) for their ability to inhibit human neutrophil elastase in an in vitro assay. Podachaenin was the most active compound with an IC(50) value of 7 microM. SLs do not covalently bind to the amino acids of the catalytic triad, thus differing from other elastase inhibitors with a lactone moiety. In contrast to most other biological activities of SLs HNE inhibition is not mediated by alpha,beta-unsaturated carbonyl functions. Ligand binding calculations using the X-ray structure of HNE and the program FlexX revealed structural elements which are a prerequisite for their inhibitory activity.

Inhibition of neutrophil elastase activity by phenolic compounds from plants.

The influence of 40 phenolic compounds from plants were tested on the enzymatic activity of neutrophil elastase (EC 3.4.21.37). Among the flavonoids especially the compounds with a catecholic structure showed a strong inhibitory activity in the range of mumol/l, hyperosid was the strongest inhibitor with an IC50 of about 0.3 mumol/l. Lipophilic caffeic acid esters and phenolic compounds with catecholic structure elements in general inhibited the enzyme. Because of the specific role of neutrophil elastase in the inflammatory process its inhibition by phenolic natural compounds might be one explanation for the use of medicinal plants containing phenolic compounds in the treatment of inflammation.

Inhibition of neutrophil elastase activity by cinnamic acid derivatives from Cimicifuga racemosa.

Caffeic acid, fukinolic acid as well as cimicifugic acids A, B, E and F isolated from the rhizomes of Cimicifuga racemosa (Ranunculaceae) inhibited the activity of neutrophil elastase (EC 3.4.21.37) in a dose-dependent manner. An IC50 of 93 mumol/L was determined for caffeic acid and 0.23 mumol/L for fukinolic acid. Cimicifugic acid A inhibited the enzyme with an IC50 of 2.2 mumol/L, cimicifugic acid B with 11.4 mumol/L, and cimicifugic acid F with 18 mumol/L. Cimicifugic acid E was only a very weak inhibitor.

Differential expression of osteopontin, PC4, and CEC5, a novel mRNA species, during in vitro angiogenesis.

The formation of new capillaries from preexisting blood vessels, a process termed angiogenesis, plays a key role in many physiological and pathological conditions such as wound healing, embryogenesis, and tumor growth. The aim of this study was to identify changes in endothelial cell gene expression specifically associated with angiogenesis. Using an in vitro model and the differential display strategy, we compared gene expression patterns of rat microvascular endothelial cells cultured in two (2D) and three-dimensional (3D) culture. In 2D culture, the cells express actin and proliferate, whereas in 3D culture actin expression is downregulated, and the cells are mitotically quiescent and reorganize into vascular tubes. We identified three differentially expressed genes, osteopontin, PC4, and CEC5, a novel mRNA species, with homology to calmodulin-dependent protein kinases. The expression patterns were confirmed by Northern blot analysis. In conclusion, the analysis of gene expression in endothelial cells in 3D and 3D culture allows the identification of genes differentially expressed during angiogenesis. These genes or proteins may serve as targets for therapeutic modulation of angiogenesis.

[Initial results of perioperative antibiotic premedication with halospor and gentamycin in cesarean section]. / Erste Ergebnisse der perioperativen Antibiotikaprophylaxe mit Halospor und Gentamycin beim Kaiserschnitt.

The perioperative application of antibiotics in prophylaxis of infections is disputed. In a preliminary prospective study the infections morbidity of 44 patients after caesarean section was determined to investigate the effect of short term prophylaxis with halospor and gentamycine. A control group of 104 patients remained without any antibiotic prophylaxis. The patients of the prophylaxis group showed a statistically significant reduction of postoperative infectious morbidity. The costs are equalized by reduction in therapeutic applications of antibiotics.