[Update in Obstetric Anesthesia - Tried and Trusted Methods, Controversies and New Perspectives]. / Geburtshilfliche Anästhesie: Altbewährtes, Kontroversen und neue Perspektiven ­ Teil 2.

Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the society for Obstetric anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years (first event on April 1, 2000, most recently held on February 27, 2016, in Munich): the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" [1], [2]."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.

[Update in Obstetric Anesthesia: Tried and Trusted Methods, Controversies and New Perspectives - Part 1]. / Geburtshilfliche Anästhesie: Altbewährtes, Kontroversen und neue Perspektiven ­ Teil 1.

Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the Society for Obstetric Anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years: the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" 1, 2."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.

[Antiplatelet drugs - implications for the anesthesiologist]. / Perioperative Thromboseprophylaxe - Thrombozytenaggregationshemmer - Bedeutung für die Anästhesie.

Aspirin and thienopyridines are the mainstay of platelet aggregation inhibition in patients with acute coronary syndromes and patients receiving coronary artery stents. After elective coronary artery stenting, they are prescribed for up to 3 months after bare metall stents and for at least 12 months after drug-eluting stents, thereby significantly reducing the risk of acute stent thrombosis. During this time period, patients should not undergo elective surgery. However, they may present with surgically amenable diseases that do not allow further delay. In these cases a careful risk-benefit analysis is required to elucidate the risk of major surgical bleeding versus the risk of major cardiovascular events with aspirin to be continued throughout the perioperative period. Current evidence does not suggest to use platelet function tests to guide therapy under these circumstances. If major bleeding occurs under dual platelet aggregation inhibition, the most appropriate interventions are antifibrinolytics such as tranexamic acid and transfusion of platelets to counteract the platelet aggregation inhibitory effects.

Efficacy of intravenous paracetamol compared to dipyrone and parecoxib for postoperative pain management after minor-to-intermediate surgery: a randomised, double-blind trial.

BACKGROUND AND OBJECTIVE: Paracetamol has a well established pharmacological profile, but its postoperative efficacy is in question. This double-blind, placebo-controlled study was designed to compare the efficacy of intravenous paracetamol with other intravenous non-opioids as part of a multimodal concept for perioperative pain therapy. METHODS: Patients undergoing minor-to-intermediate surgery under general anaesthesia were randomly assigned to receive infusions of paracetamol (1 g every 6 h), dipyrone (1 g every 6 h), parecoxib (40 mg every 12 h) separated by infusions of physiological saline 0.9%, or placebo (0.9% saline every 6 h), respectively, for at least 48 h as part of a multimodal pain concept. Patient-controlled piritramide was administered as rescue medication. Dependent variables were recorded 1, 6, 18, 30 and 42 h after extubation and 1 week after surgery. Surgical and associated pain was scored as the primary outcome on a visual analogue scale. Additionally, time to first dose and total piritramide dosage, satisfaction, respiratory depression, nausea, vomiting, sedation, itching and sweating were recorded. RESULTS: A total of 196 patients were recruited. The efficacy of paracetamol was similar to that of the other non-opioid analgesics. Surgical pain was reduced with all non-opioids compared to placebo; there was no effect on associated pain. Piritramide dosage and incidence of side effects were not reduced. CONCLUSION: Intravenous paracetamol has equivalent efficacy to non-opioids dipyrone and parecoxib that improves postoperative pain therapy when used as part of a multimodal concept after minor-to-intermediate surgery.

[Postpartum hemorrhage--an update]. / Geburtshilfliche Anästhesie--Update postpartale Atonie.

Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. The incidence of postpartum hemorrhage appears to be increasing in developed countries due to an increased number of placenta accreta or percreta after previous Cesarean deliveries. The initial therapy of postpartum hemorrhage consists of uterotonic drugs and inspection of the uterine cavum. At the same time, optimization of the clotting potential should be initiated early. Tranexamic acid may be considered as a first line choice, followed by fibrinogen if necessary. If bleeding continues, fresh frozen plasma and packed red cells should be ordered in a ratio of 1:1, as this ratio has been shown to improve survival in trauma victims. All labor and delivery suites should have standard operating procedures for the management of postpartum hemorrhage in place with regular drills.

Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology.

BACKGROUND AND OBJECTIVES: performing neuraxial anaesthesia in patients receiving antithrombotic drugs is controversial due to the increased risk of spinal epidural haematoma. Strict adherence to the recommended time intervals between the administration of anticoagulants, neuraxial blockade and the removal of catheters is thought to improve patient safety and reduce the risk of haematoma. Appropriate guidelines have been prepared by a number of national societies of anaesthesiologists, but they do not have universal acceptance. The introduction of new anticoagulants together with recent reports of stent thrombosis in patients with perioperative cessation of antiplatelet drugs have considerably broadened the issue and made revision necessary. To overcome deficiencies in content and applicability, the European Society of Anaesthesiology has taken the initiative to provide current and comprehensive guidelines for the continent as a whole. METHODS: extensive review of the literature. RESULTS AND CONCLUSIONS: in order to minimise bleeding complications during regional anaesthetic techniques, care should be taken to avoid traumatic puncture. If a bloody tap occurs when intraoperative anticoagulation is planned, postponing surgery should be considered. Alternatively, catheters can be placed the night before surgery. Regional anaesthesia in patients receiving full anticoagulation treatment continues to be contraindicated. Catheter manipulation and removal carry similar risks to insertion and the same criteria should apply. Appropriate neurological monitoring is essential during the postoperative recovery period and following catheter removal. The final decision to perform regional anaesthesia in patients receiving drugs that affect haemostasis has to be taken after careful assessment of individual risks and benefits.

Preeclampsia and anaesthesia.

PURPOSE OF REVIEW: The most recent findings on preeclampsia with a focus on maternal mortality, haemodynamic changes, clotting disorders and anaesthesia are reviewed. RECENT FINDINGS: Preeclampsia is a major cause of maternal morbidity and mortality. Cerebral haemorrhage is the single most common cause of maternal death in preeclampsia and currently far outnumbers pulmonary oedema. Although there was a focus on diastolic pressure in the past, the present recommendations of the National Enquiries into Maternal Death advocate treatment of systolic blood pressures above 160 mmHg in order to avoid intracranial bleeding. Noninvasive monitoring techniques such as pulse wave analysis and echocardiography have provided new insights into the haemodynamic changes of preeclampsia and corroborated previous findings. In early-onset preeclampsia, the most common haemodynamic features include vasoconstriction, low cardiac output and low filling pressures. Neuraxial anaesthesia aids in providing stable haemodynamics, the incidence of hypotension and the need for vasopressors are reduced compared with healthy parturients, and cardiac output is unchanged. With cautious fluid administration, the risk of pulmonary oedema seems negligible. In order to avoid spinal epidural haematoma in the presence of thrombocytopenia, spinal anaesthesia may afford the best risk-benefit analysis. It remains open to question whether thromboelastography will aid in guiding treatment in the future. SUMMARY: Cerebral haemorrhage is the major cause of maternal mortality in preeclampsia and any increases in maternal blood pressure above 160 mmHg or at induction of general anaesthesia should be treated. Traditional rapid sequence induction is, therefore, best avoided; neuraxial anaesthesia is the technique of choice.

Postoperative analgesia after knee surgery: a comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade.

BACKGROUND: The most effective ropivacaine concentration for femoral infusion after total knee arthroplasty is currently ill defined. We designed the present study to compare ropivacaine in three different concentrations (0.1, 0.2, and 0.3%) to evaluate analgesic quality, when administered as a continuous infusion with frequent infusion adjustments in patients receiving a combined femoral and sciatic nerve block. Secondary aims were to evaluate side effects such as motor blockade, rehabilitation indices, and ropivacaine plasma concentrations. METHODS: One hundred twenty-two patients undergoing total knee arthroplasty under combined general and regional anesthesia received femoral infusions of ropivacaine 0.1, 0.2, or 0.3%. Infusions were started after initial loading doses of 30 mL ropivacaine 0.5% into the femoral catheter and a sciatic catheter and were targeted to dynamic pain scores of 40 mm. Pain and side effects were assessed 1 h after tracheal extubation and on the first, second, third, fourth, and fifth postoperative days. Ropivacaine plasma concentrations were measured 24, 48, and 72 h after the start and 24 h after termination of femoral infusions in patients receiving ropivacaine 0.2% or 0.3%. RESULTS: Ropivacaine 0.1% provided ineffective analgesia. Ropivacaine 0.2% and 0.3% provided equivalent analgesia. Maximum infusion rates were 15.39 and 13.77 mL/h for ropivacaine 0.2% and 0.3%, respectively. There were no significant differences in motor blockade, mobilization, or ropivacaine plasma concentrations, which remained below toxic levels throughout the study period. CONCLUSION: Ropivacaine 0.2% and 0.3% were similar in terms of analgesic quality. Initial infusion rates should be adjusted to 15 mL/h to obtain effective analgesia.

[Prevention and treatment of hypotension during Caesarean delivery]. / Hypotonieprophylaxe und -therapie bei Regionalanästhesien zur Sectio caesarea.

Regional anesthesia for Caesarean delivery is often accompanied by a reduction in maternal blood pressure. Maternal hypotension may lead to a reduction in uteroplacental blood flow with consecutive fetal acidosis. In order to avoid reductions in uteroplacental blood flow, tremendous research has been performed, showing that the avoidance of aortocaval compression, compression of the lower extremities, and prehydration with colloids are effective in reducing maternal hypotension. Further means include the recent introduction of low dose spinal anesthesia with a combination of small amounts of local anesthetics and opioids. Nevertheless, maternal hypotension is not always preventable and the use of vasopressors is still frequently required. Although ephedrine has been considered the vasopressor of choice over the last decades, current studies show that fetal acidosis is less frequently encountered with the use of phenylephrine, which should thus be considered as a first-line agent.

[Regional anesthesia for postoperative pain control]. / Postoperative Akutschmerztherapie--Die Rolle der Regionalanästhesie.

Pain is the most frequent and straining symptom after surgery. Regardless of the severity of the surgical trauma patients may suffer from severe pain and may therefore not tolerate or even refuse important postoperative interventions for fear of pain. This may influence the outcome and worsen the prognosis of surgical patients. Physicians are therefore ethically and legally bound to care for adequate pain management. Regional anesthesia, especially epidural analgesia, is most effective to treat postoperative pain. It is discussed whether the incidence and severity of chronic postoperative pain can be reduced and postoperative complications can be prevented by this technique. Epidural analgesia may reduce the risk of postoperative complications (i.e. myocardial infarction) by reducing the surgical stress response and inhibiting the pathophysiological cascade that may trigger undesirable sequelea.

[Anesthesia for patients with congenital heart disease undergoing non-cardiac surgery]. / Nichtherzchirurgische Eingriffe bei Kindern und Erwachsenen.

An increasing number of children who have undergone corrective surgery for congenital heart disease (CHD) reach adulthood every year. These survivors defy commonly used classification schemes for adults undergoing non-cardiac surgery. Due to lack of data, the risk-benefit assessment for undergoing non-cardiac interventions must be individualized. An interdisciplinary team approach is the corner stone for the safe delivery of anesthesia to this patient population. This review is meant to equip the anesthesiologist with the necessary tools for the safe perioperative sailing of his patient suffering from CHD.

Pediatric assist with the Medos and Excor systems in small children.

Pediatric long-term ventricular support with paracorporeal assist devices is performed in only a few institutions. We report on our experience with two pediatric paracorporeal devices, which have been implanted in neonates, infants, and small children. Seven children with ages ranging from 2 weeks to 6 years and a body weight of 3 to 19 kg were provided with either a Medos or a BerlinHeart System. The underlying heart diseases included dilative cardiomyopathy (n = 3), endocardial fibroelastosis (n = 2), Ebstein anomaly, and status post redo aortic valve replacement (n = 1). All children were in New York Heart Association class IV and were inotrope dependent. Three children were provided with a Medos system and 4 children with a BerlinHeart Excor device. In 6 cases, left ventricular support, and in 1 case, right ventricular support was performed. All patients were stabilized with univentricular mechanical support. The perioperative course was uneventful, and end-organ function was well recovered. Reexploration for bleeding and evacuation of mediastinal blood clots was necessary in all three neonates but not in any of the older infants. Severe thromboembolic events were only noticed in the neonates. Successful bridge to transplantation was performed in 6 of the 7 patients (87.5%). Our late results have been quite encouraging, as they readily prove that pediatric long-term mechanical support is possible with a high quality of life and an acceptable low complication rate.

Amniotic air insufflation during minimally invasive fetoscopic fetal cardiac interventions is safe for the fetal brain in sheep.

BACKGROUND: Amniotic air insufflation during experimental fetoscopic fetal cardiac interventions greatly improves the visualization of intra-amniotic contents. The purpose of this study was to assess any histologically discernible effects from this approach on the fetal brain after short-term studies and long-term survival in sheep. METHODS: Thirty pregnant ewes between 80 and 110 days of gestation underwent amniotic air insufflation during various fetoscopic fetal cardiac interventions. After 18 short-term and 12 long-term studies, the brains of the operated fetuses and-if available-their unoperated siblings were examined for hemorrhage, embolism, infarctions, inflammatory changes, and abnormal cortical maturation. RESULTS: Amniotic air insufflation during minimally invasive fetoscopic fetal cardiac interventions did not result in any histologically discernible damage to the brain in short-term and long-term studies in any but 2 sibling sheep. In the 2 affected siblings, a small area of chronic cortical frontal lobe infarction was observed after long-term survival. CONCLUSIONS: Amniotic air insufflation during minimally invasive percutaneous fetoscopic fetal cardiac interventions is safe for the fetal brain and does not compromise maternal hemodynamics in sheep. These findings encourage further investigation of the role this technique might play during fetoscopic fetal cardiac interventions in humans.

Intra-amniotic multimodal fetal echocardiography in sheep: a novel imaging approach during fetoscopic interventions and for assessment of high-risk pregnancies in which conventional imaging methods fail.

During fetoscopic interventions, intraesophageal placement of intravascular ultrasound (US) catheters for fetal hemodynamic monitoring may result in esophageal injury in very small fetuses. Moreover, conventional fetal imaging by the transvaginal or transabdominal routes may be impossible in some high-risk pregnancies. The purpose of our study in sheep was to assess the potential of a phased-array intravascular US catheter for intra-amniotic fetal echocardiography. The catheter was percutaneously inserted into the amniotic cavity in seven pregnant ewes at between 78 to 98 days of gestation and permitted high-quality 2-D imaging of the fetal heart and multimodal Doppler assessment of fetal cardiovascular flows. Fetoscopic examination of intra-amniotic contents after intra-amniotic imaging was finished did not display any injury to intra-amniotic contents. The intra-amniotic imaging approach may provide an effective alternative in humans for monitoring during fetoscopic interventions, and to assess fetal anatomy and hemodynamics in high-risk pregnancies when sufficient images cannot be obtained by conventional routes.

The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors.

BACKGROUND: When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use. METHOD: We selectively searched for relevant publications that appeared from 2003 to February 2013, with particular consideration of the guidelines of the European Society of Cardiology, the Association of Scientific Medical Societies in Germany (AWMF), the American College of Cardiology, and the American Heart Association. RESULTS: Vitamin K antagonists (VKA), low molecular weight heparins, and fondaparinux are the established anticoagulants. The past few years have seen the introduction of orally administered selective inhibitors of the clotting factors IIa (dabigatran) and Xa (rivaroxaban, apixaban). The timing of perioperative interruption of anticoagulation is based on pharmacokinetic considerations rather than on evidence from clinical trials. Recent studies have shown that substituting short-acting anticoagulants for VKA before a procedure increases the risk of bleeding without lowering the risk of periprocedural thromboembolic events. The therapeutic spectrum of acetylsalicylic acid and clopidogrel has been broadened by the newer platelet aggregation inhibitors prasugrel and ticagrelor. Patients with drug eluting stents should be treated with dual platelet inhibition for 12 months because of the risk of in-stent thrombosis. CONCLUSION: Anticoagulants and platelet aggregation inhibitors are commonly used drugs, but the evidence for their perioperative management is limited. The risks of thrombosis and of hemorrhage must be balanced against each other in the individual case. Anticoagulation need not be stopped for minor procedures.

Patients and complication with off-pump vs. on-pump cardiac surgery - a single surgeon experience.

BACKGROUND: Off-pump operations (OPCAB) are growingly used for patients with coronary artery disease (CAD) and may be associated with improved outcomes when compared with coronary artery bypass grafting (CABG) using extracorporeal circulation (ECC), especially in patients with comorbidities. The aim of this study is to compare the intra- and postoperative results of OPCAB complete arterial myocardial revascularization with standard on-pump CABG under respect of comorbidities. METHODS: We report about the implementing of the off-pump technique in our institution from November 2004 to May 2006. Sixty-two patients with CABG in off-pump technique were compared to a control group of 129 patients with CABG using ECC. The off-pump technique was mostly used in patients with vascular and pulmonary diseases. All operations were performed by the same surgeon. All off-pumps were performed using both internal thoracic arteries (ITA) or left ITA and radial artery (RA) in T-graft technique, while in the on-pump group only the LITA and saphenous vein were used. The conversion rate from OPCAB to conventional CABG was 3.2% (two patients). RESULTS: Peripheral vascular disease (PVD) and chronic obstructive pulmonary disease (COPD) were significant more often in the off-pump group. Other preoperative risk factors were comparable between the groups. Operation time was significantly longer in the off-pump group. Postoperative symptomatic transient psychotic syndromes were more often in the on-pump group. Outcome was similar, despite significant longer operation time in off-pump group. CONCLUSION: Off-pump coronary artery surgery can be performed in patients with comorbidities with similar outcome compared to on-pump surgery.

Comparison of intrathecal bupivacaine and levobupivacaine combined with opioids for Caesarean section.

OBJECTIVE: To date, racemic bupivacaine is the most popular local anaesthetic for spinal anaesthesia in parturients undergoing elective Caesarean delivery. However, data suggests that S-enantiomers like levobupivacaine may produce differential sensory and motor blockade. The aim of the present study was to compare fixed doses of intrathecal hypertonic levobupivacaine 0.5% (10 mg) and bupivacaine 0.5% (10 mg) combined with either intrathecal fentanyl (10 and 20 microg), or sufentanil (5 microg) in terms of sensory and motor block characteristics. RESEARCH DESIGN AND METHODS: 60 parturients with singleton pregnancy and > 34 weeks of gestation who underwent elective Caesarean delivery participated in this randomized, double-blinded clinical trial. They received spinal anaesthesia with either levobupivacaine or bupivacaine and the above mentioned opioids added (n = 10 parturients/group). Sensory block was assessed bilaterally by loss of cold sensation, and the degree of motor block was determined according to the Bromage scale every minute until delivery, subsequently at 5-min intervals until the end of surgery, and at 15-min intervals thereafter until complete resolution of spinal anaesthesia. A visual analogue scale was used postoperatively to measure duration of analgesia at 15-min intervals. MAIN OUTCOME MEASURES: Levobupivacaine produced a significantly shorter and less pronounced motor blockade than racemic bupivacaine regardless of the kind and dose of opioid added. Duration of motor block Bromage 3 was 53 +/- 14 min, 23 +/- 18 min and 41 +/- 8 min compared to 65 +/- 25 min, 70 +/- 19 min and 65 +/- 22 min in the bupivacaine groups. Also, only n = 5/30 parturients reached Bromage 3 in the levobupivacaine groups versus n = 21/30 parturients in the bupivacaine groups. No parturient experienced intraoperative pain. Adding sufentanil 5 microg to either local anaesthetic significantly prolonged duration of effective analgesia compared to supplemental fentanyl 10 or 20 microg. CONCLUSIONS: Based on our data, 10 mg of hypertonic levobupivacaine 0.5% combined with sufentanil 5 microg was the most appropriate anaesthetic regimen in parturients undergoing elective Caesarean delivery in spinal anaesthesia.

The influence of new antithrombotic drugs on regional anesthesia.

PURPOSE OF REVIEW: Antithrombotic drugs are known to increase the risk of spinal epidural hematoma after neuraxial blockade. During the last few years, several new anticoagulants have been introduced, some of them more potent than the drugs currently available. More potency, however, may also indicate a higher risk of bleeding. RECENT FINDINGS: Case series from the last few years indicate that spinal epidural hematoma is more common then previously estimated, with a prevalence from 1: 100,000 in obstetric patients to as high as 1: 3,600 in female orthopedic patients. In order to diminish this risk, most national societies have issued guidelines in which time intervals were established between administration of antithrombotic drugs and performance of neuraxial blockade. SUMMARY: Guidelines are perceived to be capable of reducing the incidence of spinal epidural hematoma with the inherent risk of permanent paraplegia. These guidelines, however, will only be a valuable aid for clinicians if they are constantly updated and newer antithrombotic drugs are included. Although the resurge of peripheral nerve blocks may diminish patient hazards, deep nerve blocks such as lumbar sympathetic blockade are not devoid of serious complications and should probably be handled in the same way as neuraxial blockade.