[Terror attacks : Recommendations for cooperation between police, hospitals and non-police security services]. / Lebensbedrohliche Einsatzlagen : Handlungsempfehlung zur Zusammenarbeit zwischen Polizei, Kliniken und nichtpolizeilicher Gefahrenabwehr.

BACKGROUND: The risk of terrorist attacks in the Federal Republic of Germany is present and is currently increasing. Publicly funded acute care hospitals and their owners are involved in disaster control as part of their remit and are responsible for taking comprehensive precautions to ensure their operational capability in the event of disasters. This mandate must also be ensured in the event of terrorist attacks and amok incidents. For this purpose, an optimal cooperation between preclinical and clinical care is indispensable. AIM: Recommended actions for collaboration between nonclinical and clinical planning to manage a mass casualty incident in terrorist life-threatening response situations are presented. MATERIAL AND METHODS: The Inter-Hospital Security Conference Baden-Württemberg (IHSC BW) is an association of representatives of acute hospitals in Baden-Württemberg, the Ministry of the Interior, Digitalization and Migration Baden-Württemberg, the Ministry of Social Affairs and Integration Baden-Württemberg, the State Police Headquarters Baden-Württemberg and the Baden-Württemberg Hospital Association. From 2018 to 2020, the IHSC BW developed recommendations for action on cooperation between police, hospitals and non-police emergency response. The recommendations for action were agreed by the group members in 6 working sessions and initialled in two subsequent video conferences. A recommendation was considered adopted when the IHSC BW plenary assembly finally gave its approval with an absolute majority. RESULTS AND DISCUSSION: Competence-based interface solutions for a smooth cooperation between prehospital and hospital management in the care of patients who have become victims of a terrorist attack are to be demanded. For preliminary planning, the establishment of a local safety conference at the county disaster control authority level with the following participants is recommended: disaster control authority, fire department, regional police headquarters, chief emergency physician, rescue services and disaster control officers of affected clinics. It is recommended to set up a joint command and situation center (CSC), where management personnel from the police, rescue service, fire department and disaster control can meet to organize the handling of the incident jointly, competently and without loss of time. From this CSC, a liaison officer should then provide the clinics with information at regular intervals. Exercises should take place regularly. Cross-organizational exercises are particularly important, and this is one of the tasks of the local safety conference.

[Resilience against IT attacks in hospitals : Results from an exercise in a German university hospital]. / Resilienz gegen IT-Angriffe an Kliniken : Ergebnisse einer Stabsrahmenübung an einem Universitätsklinikum.

BACKGROUND: According to the legal definition healthcare systems and their components (e.g., hospitals) are part of the critical infrastructure of modern industrial nations. During the last few years hospitals increasingly became targets of cyber attacks causing severe impairment of their operability for weeks or even months. According to the German federal strategy for protection of critical infrastructures (KRITIS strategy), hospitals are obligated to take precautions against potential cyber attacks or other IT incidents. OBJECTIVE: This article describes the process of planning, execution and results of an advanced table-top exercise which took place in a university hospital in Germany and simulated the first 3 days after a cyber attack causing a total failure of highly critical IT systems. MATERIAL AND METHODS: During a first stage lasting about 8 months IT-dependent processes within the clinical routine were identified and analyzed. Then paper-based and off-line back-up processes and workarounds were developed and department-specific emergency plans were defined. Finally, selected central facilities such as pharmacy, laboratory, radiology, IT and the hospitals crisis management team took part in the actual disaster exercise. Afterwards the participants were asked to evaluate the exercise and the hospitals cyber security using a questionnaire. On this basis the authors visualized the hospital's resilience against cyber incidents and defined short-term, medium-term and long-term needs for action. RESULTS: Of the participants 85% assessed the exercise as beneficial, 97% indicated that they received adequate support during the preparations and 75% had received sufficient information; however, only 34% had the opinion that the hospital's and their own preparedness against critical IT failures were sufficient. Before the exercise took place, IT-specific emergency plans were present only in 1.7% of the hospital facilities but after the exercise in 86.7% of the clinical and technical departments. The highest resilience against cyber attacks was not surprisingly reported by facilities that still work routinely with paper-based or off-line processes, the IT department showed the lowest resilience as it would come to a complete shutdown in cases of a total IT failure. CONCLUSION: The authors concluded that the planning phase is the most important stage of developing the whole exercise, giving the best opportunity for working out fallback levels and workarounds and through this strengthen the hospitals resilience against cyber attacks and comparable incidents. A meticulous preparedness can minimize the severe effects a total IT failure can cause on patient care, staff and the hospital as a whole.

[Escalation and de-escalation concept for intensive care beds in hospitals reserved for COVID-19]. / Eskalations­/Deeskalationskonzept zur COVID-19-bedingten Freihaltung von Intensivkapazitäten an Kliniken.

BACKGROUND: Since the spread of Severe Acute Respiratory Syndrom Corona Virus 2 (SARS-CoV­2) in Germany, intensive care beds have been kept free for patients suffering from Corona Virus Disease (COVID-19). Also, after the number of infections had declined, intensive care beds were kept free prophylactically; however, the percentage of beds reserved for COVID-19 differ in the individual federal states in Germany. The aim of this article is to define a necessary clearance quota of intensive beds for COVID-19 patients in Germany. An escalation and de-escalation scheme was created for rising and falling numbers of infected patients. METHODS: Data from the COVID-19 resource board of the state of Baden-Württemberg, the daily situation report of the Robert Koch Institute (RKI), the register of COVID-19 intensive care beds of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) as well as the daily report of COVID-19 Baden-Württemberg from April to November 2020 were used for the calculation. RESULTS: At the end of November 2020 approximately 13.5% of intensive care beds in Germany were used by COVID-19 patients. Of all persons tested positive for SARS-CoV­2, 1.5% were admitted to an intensive care unit. The hospitalization rate was 6% and the mean age of infected persons was 43 years. Based on these numbers hospitals are recommended to keep 10% of intensive care beds available for COVID-19 patients in the case of less than 35 new infections/100,000 in the catchment area, 20% should be kept free in case of an advanced warning level of 35 new infections/100,000 inhabitants and 30% for a critical limit of 50 new infections/100,000 inhabitants. Further internal hospital triggers, such as the occupancy of the intensive care beds with COVID-19 patients, should be considered. CONCLUSION: If the number of infections is low a general nationwide retention rate of more than 10% of intensive care beds for COVID-19 patients is not justified. Locally increasing numbers of infections require a local dynamic approach. If the number of infections increases, the free holding capacity should be increased according to a step by step concept in close coordination with the local health authorities and other internal hospital triggers. In order not to overwhelm hospital capacities in the event of local outbreaks, a corresponding relocation concept should be considered at an early stage.

[Provisioning of personal protective equipment in hospitals in preparation for a pandemic]. / Bevorratung persönlicher Schutzausrüstung in Kliniken zur Vorbereitung auf eine Pandemie.

BACKGROUND: At the beginning of the SARS-CoV­2 outbreak, personal protective equipment (PPE) was scarce worldwide, leading to the treatment of patients partially without sufficient protection for the medical personnel. In order to be prepared for a new epidemic or pandemic or a "second wave" of COVID-19 outbreak and to meet a renewed deficiency of PPE, considerations were made on how personnel and patients can be better protected by appropriate provisioning. OBJECTIVE: The aim of this study was to develop a tool to predict the necessary amount of PPE to be in stock at a transregional university hospital for a certain period of time during a pandemic. MATERIAL AND METHODS: The consumption of PPE needed for every patient was calculated based on the following data of the Ulm University Hospital: the total consumption of healthcare workers' PPE for April 2020 recorded by the materials management department and the number of patients suffering from COVID-19 and their treatment days. From the amount of PPE necessary for every patient in the intensive care unit (ICU) or in an infection ward, a PPE calculator was created in which the estimated amount of PPE can be calculated with the input variables "patients in intensive care unit", "patients in infection ward" and "treatment days". To validate the PPE calculator, the actual consumption of PPE for May 2020 at the Ulm University hospital was compared to the theoretically calculated demand by the PPE calculator. RESULTS: In April 2020 PPE consisting of 18 different items were kept in stock at Ulm University Hospital and in total 1,995,500 individual items were used. 22 intensive care patients with 257 nursing days and in the infection ward 39 patients with 357 nursing days were treated for COVID-19 disease, leading to a total of 603.2 man-days. A total of 34,550 KN95 masks, 1,558,780 gloves and 1100 goggles or protective visors were used, with a daily average of 49 NK95 masks and 2216 gloves required per ICU patient. In May 2020, 6 ICU patients and 19 patients in infection wards were treated for COVID-19 with 34 nursing days in intensive care and 201 nursing days in infection wards. The use of PPE material was 39% lower than in the previous month but in absolute terms 82% and on average 39% higher than calculated. CONCLUSION: The developed tool allows our hospital to estimate the necessary amount of PPE to be kept in stock for future pandemics. By taking local conditions into account this tool can also be helpful for other hospitals.

[Terrorist attack training exercise-What can be learned? : Baden-Württemberg counterterrorism exercise (BWTEX)]. / Terrorismusabwehrübung ­ Was können wir daraus lernen? : Baden-Württembergische Terrorismusabwehr Exercise (BWTEX).

BACKGROUND: There is a risk of terror attacks in the Federal Republic of Germany, which might increase in the future. A timely comprehensive strategy for treatment and care of a large number of casualties helps minimize chaos and improve the outcome of patients. Adequate training is vital for successful implementation of an emergency plan. Therefore, the effectiveness of training should be assessed and evaluated; however, data collection capabilities for training events are extremely limited, so that publications on the topic are almost impossible to find. OBJECTIVE: This study aimed to collect data from a simulated terrorist attack in order to draw conclusions from a clinical point of view concerning the improvement of preclinical and clinical management, taking interface problems into consideration. MATERIAL AND METHODS: On 19 October 2019 the Ministry of the Interior, Digitalization and Migration of Baden-Württemberg conducted a large-scale simulation of a terrorist attack in the city center of Constance, called the Baden-Württemberg counterterrorism exercise (BWTEX). The simulation included an explosion of a car bomb as well as the use of firearms by terrorists. The large scale of the simulation with the high number of participants in combination with close cooperation between military and civil forces was unprecedented. The police force, the armed forces, civil protection forces, air rescue teams and staff from Constance, Friedrichshafen and Sigmaringen regional hospitals in southwest Germany worked together to treat simulated injuries to victims of the attack. The following parameters were recorded when the injured patients arrived at the hospital: prehospital triage time, prehospital triage score, initial treatment and quality of documentation on site as well as triage time, triage score, injury severity scale (ISS) score based on the specified injury pattern, treatment, and quality of documentation on hospital arrival. RESULTS: Out of a total of 84 "injured patients" 55 were admitted to hospital and 80% were triaged at the scene. Injured patients of triage category 1 (TK1 red: life-threatening injury, immediate treatment) arrived at the hospital 198 ± 50 min after the attack, injured patients of triage category 2 (TK2 yellow: severely injured, urgent treatment) after 131 ± 44 min and injured patients of triage category 3 (TK3 green: slightly injured, non-urgent treatment) arrived after 157 ± 46 min. There was no significant difference in terms of arrival time at the hospital between the triage scores (r = 0.2) or between the ISS scores (r = 0.43). The authors assume that approximately 44% of TK1 patients would have died due to avoidable time delays. Prehospital medical documentation was insufficient in 78% and insufficient in 65% in the hospitals. CONCLUSION: A mass casualty incident resulting from a terrorist attack differs greatly from a conventional mass casualty incident. The scene of the attack has to be evacuated as quickly as possible, which means that a large number of patients arrive untreated at the nearest hospitals. The setting up of treatment facilities in city centers and areas close to the city seems to be counterproductive because the time delay may result in higher mortality rates of victims. The particularities of mass casualties caused by a terrorist attack have to be incorporated into terrorist attack training.

[Inhalational analgosedation in the intensive care unit : Risk of malignant hyperthermia]. / Inhalative Analgosedierung auf der Intensivstation : Gefahr einer malignen Hyperthermie.

BACKGROUND: According to the 2010 S3 Guidelines, analgosedation is an option for ventilated patients in intensive care units (ICU). Therefore, adverse effects of volatile anesthetics can occur in areas outside of surgical medical fields. OBJECTIVE: The aim is to inform ICU physicians about the clinical and legal challenges of a life-threatening pharmacogenetic reaction to inhalational anesthetics, malignant hyperthermia (MH). DISCUSSION: Consequences of an MH crisis for doctors, patients, and relatives regarding patient rights legislation, as well as insurance and employment issues with respect to the German Genetic Diagnostics Act are discussed.

[Exit wave plan for structured secondary patient distribution : Logistic concept for mass victims of terrorist attacks]. / Exit-Wellenplan zur geordneten sekundären Patientenverteilung : Logistikkonzept bei Massenanfall von Terroropfern.

BACKGROUND: Following a terrorist attack a second hit is to be feared. The adequate reaction of the emergency services on site is to clear the scene. Since in such cases no treatment areas are set up at the scene of the incident, the injured are quickly admitted to the nearest hospital, either by themselves or by the emergency services and are largely untreated. Therefore, the hospital has to be ready to take in a significantly larger number of injured people in a very short period of time than after a conventional mass casualty incident. Due to the conceivably large number of wounded persons the emergency department can ensure primary medical care but nowhere near all casualties admitted to the hospital can be definitively treated. OBJECTIVE: In order to provide injured patients with individual medical care after initial treatment according to the criteria of damage control resuscitation, a concept should be developed that enables a well-organized secondary transfer to receiving hospitals with appropriate equipment. MATERIAL AND METHODS: Within a radius of 100 km from Ulm, all hospitals certified by the German Society for Trauma Surgery were contacted and asked to indicate how many emergency patients of the triage categories T1 (red), T2 (yellow) and T3 (green) could be admitted and treated around the clock (24/7). Special features such as a helicopter landing pad, neurosurgical care and pediatric traumatology care were considered. RESULTS: Of the 32 hospitals within a 100 km radius of Ulm 29 (91%) provided information on the admission capacity. In these hospitals 45 T1, 121 T2 and 333 T3 patients could be admitted around the clock (24/7). A helicopter landing pad is available at 26 of the 29 hospitals (90%), 11 hospitals (38%) can treat patients for emergency neurosurgery and 18 hospitals (62%) have the possibility of pediatric traumatological emergency care. Based on this information the structured exit wave plan was developed, which enables a secondary transfer of at least 100 patients to qualified trauma centers. CONCLUSION: The University Hospital of Ulm has made preparations to admit at least 100 injured patients for initial medical treatment following a terrorist attack. This corresponds to 10% of the hospital beds as required in the literature. Together with the neighboring Military Hospital and the University and Rehabilitation Hospital Ulm up to 300 injured patients can be treated; however, the number of available intensive care unit (ICU) beds and capacities in normal wards for definitive care is much lower, therefore, patients treated according to the principles of damage control resuscitation have to be relocated. By documenting the capacity of the hospitals within a 100 km radius around Ulm and taking their specific features into account, an exit wave plan could be created that enables patient distribution for definitive care without time-consuming procedures.

[Stocks of dantrolene in anesthesia and intensive care units in Germany : Nationwide online survey with 1673 participants]. / Dantrolenbevorratung in Anästhesie und Intensivmedizin in Deutschland : Bundesweite Onlineumfrage mit 1673 Teilnehmern.

BACKGROUND: A malignant hyperthermia (MH) crisis is a potentially fatal complication in anesthesia and intensive care units (ICU). Rapid administration and adequate dosage of dantrolene is the only known effective pharmacological and causal treatment of an MH crisis. International anesthesiology societies recommend an initial dose of 2.0-2.5 mg/kg body weight (BW). The necessary total dosage should be titrated up to 10 mg/kg BW depending on the effectiveness. OBJECTIVE: The goal of this study was an analysis of the stocking situation of dantrolene in Germany. A national survey was conducted amongst members of the German Society of Anaesthesia and Intensive Care (DGAI). MATERIAL AND METHODS: A questionnaire consisting of 19 items was posted online to all DGAI members from 2 September to 30 September 2015. The questionnaire dealt with characterization of the participants, the administration of triggering substances in the operating room and in the ICU of the respective hospitals. The main part covered the amount of stocked dantrolene, the place of storage and emergency availability of stocked dantrolene from elsewhere. RESULTS: The questionnaire was posted online to 12,415 DGAI members with a response rate of 13.5% (n = 1673). The highest response rate was from 259 directors and heads of anesthesiology units representing 28.3%. In total 93,7% of participants use volatile anesthetics and 82,3% use succinylcholine. In the event of an MH-crisis 40.4% of participants have 36 or more vials of dantrolene available within 5 min, 27.4% have only 24 vials and 18.7% only have 12 vials. Of the anesthesiologists in outpatient surgery 70.6% have a dantrolene stock of less than 36 vials. In those cases with insufficient dantrolene stock, 35.5% of hospitals have no agreement with neighboring hospitals. In the ICU setting, 51.8% of responding participants indicated the use of volatile anesthetics, but only 25.7% stock dantrolene in the ICU. For succinylcholine, 77.3% stated using the drug in the ICU, and 26.0% have a dantrolene stock in the ICU. CONCLUSION: Almost all anesthesiologists participating in the online survey use volatile anesthethics and/or succinylcholine. Whereas almost all participants have access to dantrolene, more than half of the units have a stock of dantolene, which is less than that recommended by the DGAI. In the case of low dantrolene stock, only 61% of anesthesia departments have access to additional dantrolene within a time frame of 15min . The results of this online survey demonstrate that the stock of dantrolene may be insufficient in some German hospitals and anesthesiology practices.

[Impact assessment of inadequate hospital disaster management : Reflection based on a risk model]. / Folgen einer unzureichenden Krankenhaus-Katastrophenplanung : Betrachtung anhand eines Risikomodells.

BACKGROUND: According to legal regulations alarm and emergency plans have to be developed and kept current in hospitals. However, often neither the hospital administration, nor the medical employees and nursing staff pay the necessary attention to these alarm and evacuation plans. In particular, risks and consequences - including financial ones - due to insufficient planning, are not adequately considered. OBJECTIVES: Risks in hospitals are assessed based on a risk analysis. The risk assessment evaluates, whether the risk is acceptable, critical or unacceptable. Parameters for the risk analysis are the magnitude of damage and number of affected people. The intention of this paper is to evaluate whether there is a connection between estimated risk, quality of risk planning, and financial damage. MATERIALS AND METHODS: We visualized the risk analysis as a two-dimensional matrix. In addition, we introduced disaster planning quality as a third dimension and calculated the dependency between risk and planning quality and also between the resulting damage level and the planning quality. RESULTS: We showed that a poor disaster planning quality increases the unacceptable risk exponentially. Risk assessment can also draw conclusions about the extent of financial damage caused, for example fires, terrorist attacks or infrastructure failure. The amount of damage can be described as a function depending on the planning deficit of emergency planning. The worse the planning quality, the higher the amount of damages for non-tolerable risks can be. CONCLUSIONS: Risk management means recognizing risks, assessing risks and managing risks. In hospitals, this mostly means using a critical incident reporting system (CIRS), however risk management in the sense of disaster planning is largely unknown. With a three-dimensional risk matrix, we showed a clear correlation between the quality of disaster planning and relative risk or financial damage. To substantiate the presented theoretical considerations, however, further research must be designed and implemented.

[Pharmacogenetics in anesthesia and intensive care medicine : Clinical and legal challenges exemplified by malignant hyperthermia]. / Pharmakogenetik in Anästhesie und Intensivmedizin : Klinische und juristische Herausforderung am Beispiel der Malignen Hyperthermie.

Pharmacotherapy is a key component of anesthesiology and intensive care medicine. The individual genetic profile influences not only the effect of pharmaceuticals but can also completely alter the mode of action. New technologies for genetic screening (e.g. next generation sequencing) and increasing knowledge of molecular pathways foster the disclosure of pharmacogenetic syndromes, which are classified as rare diseases. Taking into account the high genetic variability in humans and over 8000 known rare diseases, up to 20 % of the population may be affected. In summary, rare diseases are not rare. Most pharmacogenetic syndromes lead to a weakening or loss of pharmacological action. In contrast, malignant hyperthermia (MH), which is the most relevant pharmacogenetic syndrome for anesthesia, is characterized by a pharmacologically induced overactivation of calcium metabolism in skeletal muscle. Volatile anesthetic agents and succinylcholine trigger life-threatening hypermetabolic crises. Emergency treatment is based on inhibition of the calcium release channel of the sarcoplasmic reticulum by dantrolene. After an adverse pharmacological event patients must be informed and a clarification consultation must be carried out during which the hereditory character of MH is explained. The patient should be referred to a specialist MH center where a predisposition can be diagnosed by the functional in vitro contracture test from a muscle biopsy. Additional molecular genetic investigations can yield mutations in the genes for calcium-regulating proteins in skeletal muscle, e.g. ryanodine receptor 1 (RyR1) and calcium voltage-gated channel subunit alpha 1S (CACNA1S). Currently, an association to MH has only been shown for 35 mutations out of more than 400 known and probably hundreds of unknown genetic variations. Furthermore, MH predisposition is not excluded by negative mutation screening. For anesthesiological patient safety it is crucial to identify individuals at risk and warn genetic relatives; however, the legal requirements of the Patients Rights Act and the Human Genetic Examination Act must be strictly adhered to. Specific features of insurance and employment law must be respected under consideration of the Human Genetic Examination Act.

Radiological validation of tracheal tube insertion depth in out-of-hospital and in-hospital emergency patients.

We performed a 5-year, retrospective study using records of 1081 patients admitted to the trauma emergency room at a University Hospital to investigate the occurrence of tracheal tube malpositioning after emergency intubation in both the inpatient and outpatient settings, using chest radiographs and CT scans in the trauma emergency room. Prehospital patients and inpatients referred from peripheral hospitals were compared. This study showed that tracheal tube misplacements occur with an incidence of 18.2%, of which almost a third (5.7%) were placed in a main bronchus. We further show that tracheal intubation in emergency patients approximates the misplacement rates in the prehospital or in-hospital settings. We speculate that the skill level of the operator may be critical in determining the success of tracheal intubation. Based on our findings, all efforts should be made to verify the tube position with immediate radiographic confirmation after admission to the emergency room.

[Time optimized modern shock room management using digital techniques]. / Zeitoptimiertes modernes Schockraummanagement unter Einsatz digitaler Techniken.

Emergency room management means time management. A time and four color based algorithm is described to improve workflow, follow up of diagnostic procedures and initial treatment. As a result introducing the time based interdisciplinary emergency algorithm within 60 minutes all necessary treatment and diagnostic procedures were completed. This algorithm is an effective tool to improve emergency room treatment.

Hypertonic-hyperoncotic saline differentially affects healthy and glutamate-injured primary rat hippocampal neurons and cerebral astrocytes.

Hypertonic-hyperoncotic saline solutions (HHS) have been used for small-volume resuscitation and to treat intracranial hypertension and cerebral edema in neurocritical care. Little is known on the response of brain cells to direct exposure in HHS, which may occur in blood-brain barrier disruption. We studied the effects of HHS on healthy and glutamate-injured brain cells in vitro. To model a hypertonic-hyperoncotic environment, rat hippocampal neurons and cerebral astrocytes were exposed to hypertonic saline and hydroxyethyl starch (HES) added to medium for 15 minutes (final osmolarity: 350 mOsm/L in the neuronal, 373 mOsm/L in the glial medium; 2.5 mg/mL HES in both media). To simulate excitotoxicity, cells were exposed to 100 microM glutamate for 8 minutes before exposure to HHS. Cell viability was analyzed by morphology and vital dye staining; intracellular water space (WS) and glucose use were measured by scintillation spectrometry using 3-O-methyl[14C]-D-glucose and [3H]2-deoxy-D-glucose ([3H]2-DG). After 24 hours, exposure to HHS added to medium caused a 30% reduction in viability of healthy neurons (P < .05), but did not exacerbate the glutamate-induced 50% decrease in neuronal survival. One hundred percent astrocyte viability remained unchanged. The WS of astrocytes and surviving neurons was negligibly altered. Exposure to HHS added to medium caused a 35% reduction in [3H]2-DG in healthy and glutamate-injured neurons (P < .05), but did not affect [3H]2-DG in astrocytes. Our data show that HHS may potentially injure hippocampal neurons. Preserved WS values imply that live cells maintained volume regulation capabilities, indicating a lack of dehydration 24 hours after exposure to HHS. Impaired glucose use predisposes neurons to disturbed metabolism, which may influence neuronal outcome after brain injury.

Intraoperative monitoring in neuroanesthesia: a national comparison between two surveys in Germany in 1991 and 1997. Scientific Neuroanesthesia Research Group of the German Society of Anesthesia and Intensive Care Medicine.

UNLABELLED: Two surveys initiated by the Neuroanesthesia Research Group of the German Society of Anesthesia and Intensive Care Medicine examined the practice of intraoperative monitoring during intracranial procedures in Germany in 1991 and 1997. Questionnaires were mailed to departments that were registered members of the German Society of Anesthesia and Intensive Care Medicine and that provided neuroanesthesia service on a routine basis in 1991. In 1997, the survey was repeated in the 1991 respondents. In 1991, 68 departments and in 1997, 44 departments returned completed questionnaires, indicating a response rate of 87% for 1991 and of 65% for 1997. Compared with 1991, the standards for monitoring, such as surveillance of oxygenation, ventilation, circulation, and body temperature, were universally applied in adult and pediatric patients in 1997. Overall, there was a 20% increase in neuromuscular blockade monitoring and in the use of electroencephalography and evoked potentials in 1997 compared with 1991. Further brain-specific monitoring was rarely provided in 1997. Overall, jugular venous oximetry was used in 20% and transcranial Doppler ultrasonography in 15% of responding hospitals. To detect venous air embolism in sitting patients, 75% of all responding hospitals used precordial Doppler ultrasonography in both years, whereas transesophageal echocardiography was more often used in 1997 (38%) as compared with 1991 (17%). IMPLICATIONS: Standards of anesthetic monitoring were surveyed in neuroanesthesia in Germany in 1991 and 1997. Central nervous system monitoring was not the standard of practice.

Anaesthetic management of neurosurgical patients.

Anaesthetic care of neurosurgical patients increasingly involves management issues that apply not only to 'asleep patients', but also to 'awake and waking-up patients' during and after intracranial operations. On one hand, awake brain surgery poses unique anaesthetic challenges for the provision of awake brain mapping, which requires that a part of the procedure is performed under conscious patient sedation. Recent case reports suggest that local infiltration anaesthesia combined with sedative regimens using short-acting drugs and improved monitoring devices have assumed increasing importance. These techniques may optimize rapid adjustments of the narcotic depth, providing analgesia and patient immobility yet permitting a swift return to cooperative patient alertness for functional brain tests. Regional anaesthesia and peripheral nerve blocks were used to prevent uncontrolled movements in special cases of intractable seizures. However, few of these strategies have been evaluated in controlled trials. Awake craniotomy for tumour removal is performed as early discharge surgery. Meticulous consideration of postoperative patient safety is therefore strongly advised. On the other hand, waking-up patients or the emergence from general anaesthesia after brain surgery is still an area with considerable variation in clinical practice. Developments indicate that fast-acting anaesthetic agents and prophylactic strategies to prevent postoperative complications minimize the adverse effects of anaesthesia on the recovery process. Recent data do not advocate a delay in extubating patients when neurological impairment is the only reason for prolonged intubation. An appropriate choice of sedatives and analgesics during mechanical ventilation of neurosurgical patients allows for a narrower range of wake-up time, and weaning protocols incorporating respiratory and neurological measures may improve outcome. In conclusion, despite a lack of key evidence to request 'fast-tracking pathways' for neurosurgical patients, innovative approaches to accelerate recovery after brain surgery are needed.

[Neuroprotection in neuroanesthesia: current practices in Germany]. / Neuroprotektion in der Neuroanästhesie. Die gegenwärtige Praxis in Deutschland.

UNLABELLED: This survey collected and analyzed data on the current practice of clinical neuroprotection in neuroanesthesia in Germany. METHODS: The data were collected by a questionnaire sent to departments of anesthesiology in Germany in 1997 which provided care for neurosurgical patients on a routine basis, and which were registered members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI). Since the questions concerning "neuroprotective therapy" were linked to a general survey on clinical neuroanesthesia performed by the scientific neuroanesthesia working group of the DGAI, the only departments that were assessed were those which had participated in an earlier study on neuroanesthesia in 1991. RESULTS: Of the completed questionnaires 63% could be included in the analysis. Approximately 75,000 cases were thus evaluated. Therapy varied considerably between departments. Following head trauma 69% of injured patients were managed with enhanced cerebral perfusion pressure (CPP) within the range of 70-90 mmHg. If necessary, CPP increase was induced by vasopressors (exogenous supply of catecholamines in 100% of instances) and the administration of fluids (97% of instances). The most commonly used therapeutic approaches to treat intracranial hypertension were mannitol (95% of instances), hyperventilation (91% of instances), cerebrospinal fluid drainage (89% of instances), and barbiturates (86% of instances). Tris (hydroxymethyl)-aminomethane was administered in almost 49%, mild hypothermia in 37%, and hypertonic-hyperoncotic solutions in 28% of patients treated for an increase in intracranial pressure. Following intracranial aneurysm surgery "triple-H" therapy was used in 74% of patients, applied as hemodilution in 94% and as hypervolemia and hypertension in 87% of instances. Mild hypothermia was employed as a method of neuroprotection in 54% of the departments involved. It was used in 83% of patients during perioperative care and in 52% of patients during intensive care therapy. Specific neuroprotective drugs were applied in 68% of departments, with barbiturates (38% of instances), nimodipine (23% of instances), and corticosteroids (10% of instances) as the main agents named. These brain-protective medications were administered especially in intracranial hypertension in 30%, in intracranial aneurysms in 21%, and in subarachnoid hemorrhages subsequent to head trauma in 18% of instances described. CONCLUSION: These findings demonstrate that the neuroprotective therapy administered in anesthesiological departments in Germany is not yet standardized, i.e., there is a wide variation. Although outcome was not assessed with this survey, it is conceivable that algorithms based on logical approaches in the sense of evidence-based medicine could serve as tools to reduce morbidity and mortality.

S(+)-ketamine up-regulates neuronal regeneration associated proteins following glutamate injury in cultured rat hippocampal neurons.

In previous studies, racemic ketamine improved neurological outcome after experimental brain injury and S(+)-ketamine demonstrated neuroprotective effects in neurons after damage in vitro. We compared the expression of regeneration-associated proteins in rat hippocampal neurons after glutamate injury and treatment with S(+)-ketamine versus racemic ketamine. Following an 8 minute exposure to 100 microM glutamate, neurons were maintained untreated or in the presence of S(+)-ketamine or racemic ketamine (10(-4) M, 10(-5) M, 10(-6) M) for one week. Growth-associated protein-43 (GAP-43) and synaptosomal-associated protein-25 (SNAP-25) was analyzed by Western Blotting, the mitochondrial transmembrane potential (MTP) by fluorescence imaging, and [3H]2-deoxy-D-glucose ([3H]2-DG) uptake by scintillation spectrometry. Seven days after exposure, GAP-43 decreased to 15% and SNAP-25 to 30% in the glutamate-injured, untreated neurons. The MTP declined to 50% and [3H]2-DG to 30%. Both S(+)-ketamine and racemic ketamine at 10(-4) M and 10(-5) M minimized the decline in MTP, almost maintaining it at control value. Additionally, S(+)-ketamine and racemic ketamine decreased the reduction in [3H]2-DG. S(+)-ketamine at 10(-4) M and 10(-5) M and racemic ketamine at 10(-4) M reduced the decline in SNAP-25 to 60% of controls (P < .05). However, S(+)-ketamine at 10(-4) M and 10(-5) M only reversed the decrease in GAP-43 to 50% and 40% of controls, respectively (P < .05). We conclude that the synthesis of a growth-associated protein related to plasticity and repair in the adult nervous system is increased by S(+)-ketamine but is not increased by racemic ketamine.

Guidelines for the treatment of acidaemia with THAM.

THAM (trometamol; tris-hydroxymethyl aminomethane) is a biologically inert amino alcohol of low toxicity, which buffers carbon dioxide and acids in vitro and in vivo. At 37 degrees C, the pK (the pH at which the weak conjugate acid or base in the solution is 50% ionised) of THAM is 7.8, making it a more effective buffer than bicarbonate in the physiological range of blood pH. THAM is a proton acceptor with a stoichiometric equivalence of titrating 1 proton per molecule. In vivo, THAM supplements the buffering capacity of the blood bicarbonate system, accepting a proton, generating bicarbonate and decreasing the partial pressure of carbon dioxide in arterial blood (paCO2). It rapidly distributes through the extracellular space and slowly penetrates the intracellular space, except for erythrocytes and hepatocytes, and it is excreted by the kidney in its protonated form at a rate that slightly exceeds creatinine clearance. Unlike bicarbonate, which requires an open system for carbon dioxide elimination in order to exert its buffering effect, THAM is effective in a closed or semiclosed system, and maintains its buffering power in the presence of hypothermia. THAM rapidly restores pH and acid-base regulation in acidaemia caused by carbon dioxide retention or metabolic acid accumulation, which have the potential to impair organ function. Tissue irritation and venous thrombosis at the site of administration occurs with THAM base (pH 10.4) administered through a peripheral or umbilical vein: THAM acetate 0.3 mol/L (pH 8.6) is well tolerated, does not cause tissue or venous irritation and is the only formulation available in the US. In large doses, THAM may induce respiratory depression and hypoglycaemia, which will require ventilatory assistance and glucose administration. The initial loading dose of THAM acetate 0.3 mol/L in the treatment of acidaemia may be estimated as follows: THAM (ml of 0.3 mol/L solution) = lean body-weight (kg) x base deficit (mmol/L). The maximum daily dose is 15 mmol/kg for an adult (3.5L of a 0.3 mol/L solution in a 70kg patient). When disturbances result in severe hypercapnic or metabolic acidaemia, which overwhelms the capacity of normal pH homeostatic mechanisms (pH < or = 7.20), the use of THAM within a 'therapeutic window' is an effective therapy. It may restore the pH of the internal milieu, thus permitting the homeostatic mechanisms of acid-base regulation to assume their normal function. In the treatment of respiratory failure, THAM has been used in conjunction with hypothermia and controlled hypercapnia. Other indications are diabetic or renal acidosis, salicylate or barbiturate intoxication, and increased intracranial pressure associated with cerebral trauma. THAM is also used in cardioplegic solutions, during liver transplantation and for chemolysis of renal calculi. THAM administration must follow established guidelines, along with concurrent monitoring of acid-base status (blood gas analysis), ventilation, and plasma electrolytes and glucose.

Basic fibroblast growth factor reduces lactic acid-induced neuronal injury in rat hippocampal neurons.

OBJECTIVE: To evaluate the long-term effects of lactic acidosis and to examine a potential neuroprotective role of basic fibroblast growth factor (bFGF) on hippocampal neurons. DESIGN: Long-term observation in a cell-culture study. SETTING: University research laboratory. SUBJECTS: Adult, differentiated, primary rat hippocampal neurons. INTERVENTIONS: Neurons were exposed to medium acidified with 20 mM lactic acid, pH 6.2, for a 10-min period, and maintained untreated or in the presence of bFGF (500 pg/mL, 1 ng/mL, 10 ng/mL, 20 ng/mL) applied after exposure. MEASUREMENTS AND MAIN RESULTS: Viability was analyzed by a dye inclusion/enzyme activity test and morphology by phase contrast and immunofluorescence microscopy. [3H]Arachidonic acid (AA) release was measured by liquid scintillation spectrometry. All cultures appeared to be unchanged during the first days after exposure to lactic acidosis. Neurodegeneration became apparent within 3 days. Seven days after exposure, cell survival decreased to 60% in lactic acidosis-injured, untreated cultures. Morphologic damage appeared as a 50% reduction in axonal and 25% reduction in dendritic arborizations. AA release increased to four-fold enhanced levels relative to control values. bFGF (1, 20, and 10 ng/ mL) enhanced neuronal viability (p < .05), and 10 ng/mL bFGF induced a maximal increase in live cells to 80% of controls. Axonal arborizations increased to 50% and dendritic arborizations to 75% of controls after 10 ng/mL bFGF (p< .05). bFGF in a dose of 20 ng/ mL enhanced axonal branching to 40% and dendrites in number and branching to 50% of controls (p< .05). bFGF (500 pg/mL, and 1 and 10 ng/mL) decreased enhanced AA (p < .05), and 10 ng/mL bFGF maximally reduced increased AA to two-fold enhanced values relative to controls. CONCLUSIONS: In vulnerable neurons, exposure to moderate lactic acidosis induces a process of cell injury with long latency. bFGF applied postinjury reduces the delayed neurodegeneration and may have neuroprotective efficacy in new therapeutic strategies to ischemia-induced cerebral injury.