[Anesthesia problem cards-indispensable yet problematic : Nationwide survey on experiences from clinical practice]. / Der Anästhesieausweis ­ unverzichtbar, aber problematisch : Deutschlandweite Umfrage zu Erfahrungen aus der klinischen Anwendung.

BACKGROUND: Anesthetic procedures may lead to severe and potentially life-threatening complications (e. g. difficult airway, allergic reactions, malignant hyperthermia). Most complications can be avoided in future anesthetic procedures with adequate preparation (e. g. awake intubation, trigger-free anesthesia). In Germany, anesthesia problem cards were introduced two decades ago to identify patients at risk and to increase patient safety by creating a standardized documentation system for anesthesia-related complications. The purpose of our study was to evaluate the utility and problems of anesthesia problem cards in clinical practice. MATERIAL AND METHODS: All registered members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) (n = 19,042) were invited to participate in an online survey on patient safety. A subsection of the survey focused specifically on anesthesia problem cards and their utility in clinical practice (e. g. field of application, issuing procedures, benefits and problems). RESULTS: The survey subsection on anesthesia problem cards was completed by 1783 participants. Most agreed that anesthesia problem cards are a useful tool to increase patient safety (n = 1502; 84.2%) and that they are routinely issued after the occurrence of anesthesia-related complications (n = 1664, 93.4%). One of the major problems noted was that patients frequently forget to bring their anesthesia problem cards when presenting for the preanesthetic assessment. This was observed by 1457 participants (81.7%). Furthermore, the information provided on anesthesia problem cards may be inadequately phrased (n = 874; 49.0%) or illegible (n = 833; 46.7%). In addition, the space for individual comments or problem solutions is insufficient (n = 811; 45.5%). Replacements for lost anesthesia problem cards with identical informational content can be issued in only 41.9% (n = 747) of the participants' departments. CONCLUSION: Anesthesia problem cards are considered a useful tool to increase patient safety and are frequently issued in clinical practice; however, in the document's current form its full potential for risk minimization cannot be exploited. Structural changes are required to increase documentation quality and reproducibility. Concerning its informational content, the spectrum of included complications and their individual solutions need to be expanded to meet the requirements of modern anesthetic practice.

Local anesthetic toxicity: Who is ready for lipid resuscitation? A survey of German Hospitals.

PURPOSE: Toxic reactions to local anesthetics are rare but potentially lethal. In fact, animal studies and case reports demonstrate that the administration of lipid emulsions after initializing cardiopulmonary resuscitation is a promising treatment option. The aim of this study was to determine how many hospitals in Germany are prepared to treat toxic reactions to local anesthetics with lipid infusion and to identify how often and what type of toxic reactions occur and if treatment was successful. Further, we aimed to elucidate if current guidelines lead to more immediate availability of lipid emulsions in direct proximity to the room where regional anesthesia is performed. METHODS: A standardized survey was sent to 1,305 German hospitals. The main question was whether lipid emulsions are readily available and if published guidelines contributed to this availability. Additionally, we asked whether local anesthetic toxicity had already successfully been treated by lipid emulsions and what type of symptoms were treated. RESULTS: We received replies from n = 509 (39%) hospitals. In 338 (66%) of the responding hospitals, lipid emulsions are readily available. Hospitals with standard operating procedures (SOPs) implemented according to published guidelines have lipids significantly more often immediately available than hospitals with just SOPs (chi-square test of independence, p-value < 0.01). Of all responding hospitals 287 (56%) have implemented a SOP for the treatment of toxic reactions to local anesthetics and 196 (39%) of the hospitals introduced the SOP because of the guidelines. In 28 (6%) of the hospitals, local anesthetic toxicity had already caused cardiac arrest with subsequent cardiopulmonary resuscitation in at least one patient. In 132 (26%) hospitals, local anesthetic toxicity had already been treated by infusing lipid emulsions. Of these hospitals 128 (96%) state this therapeutic approach was successful. Treatment with lipid emulsions was performed frequently after prodromal symptoms 83 (63%) were witnessed. CONCLUSIONS: The majority of surveyed German hospitals are prepared to treat toxic reactions to local anesthetics and published guidelines contributed to this preparedness. The infusion of lipid emulsions is a promising measure to deal with toxic reactions to local anesthetics. Since toxic reactions to local anesthetics are potentially lethal, it seems desirable that lipid emulsions are generally available in routine clinical practice. Currently, the treatment of toxic reactions to local anesthetics is mostly performed in situations (e.g. treatment of prodromal symptoms) that are not recommended by current guidelines. Further research is necessary to better define the future use of lipid emulsions in routine clinical practice.

[Nutritional therapy in traumatic brain injury : Update 2012]. / Ernährungstherapie bei Schädel-Hirn-Trauma : Update 2012.

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24 h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.

[Anesthesiological management of Caesarean sections : nationwide survey in Germany]. / Anästhesiologisches Management der Sectio caesarea : Deutschlandweite Umfrage.

BACKGROUND: The rate of Caesarean sections in Germany continues to rise. The change in anesthetic technique of choice from general to spinal anesthesia began later than in other countries and at the last survey in 2002 was not widely established. The literature on the anesthetic management of Caesarean sections contains many controversies, for example fluid preload before performing spinal anesthesia and the vasopressor of choice. Other issues have received relatively little attention, such as the level of experience of anesthesiologists working autonomously on the labour ward or the timing of antibiotic prophylaxis. The aim of the current survey was to provide an updated overview of anesthetic management of Caesarean sections in Germany. MATERIAL AND METHODS: A questionnaire was sent out to 709 departments of anesthesiology serving obstetric units in Germany. The questionnaire concerned various aspects of anesthetic management of Caesarean sections. RESULTS: A total of 360 questionnaires (50.8%) were returned of which 346 were complete and could be analyzed, accounting for 330,000 births and 90,000 Caesarean sections per year. The predominant anesthetic method used for Caesarean sections was spinal anesthesia (90.8%) using hyperbaric bupivacaine and in approximately one third of the hospitals surveyed without administering intrathecal opioids. Approximately 12% of the departments surveyed used traumatic Quincke needles. In 86.2% the vasopressor of choice was caffedrine/theodrenaline. Nitrous oxide was used in only 19.2% of departments surveyed when general anesthesia is performed. An antibiotic drug was administered in only 11% of hospitals before cord clamping. In 43.1% no neonatologist was available to treat unexpected critically ill newborns. In 32.1% of departments surveyed residents with less than 2 years experience worked autonomously on the labour ward. CONCLUSIONS: Currently the predominant anesthetic technique of choice in Germany is spinal anaesthesia and at a much higher rate than in 2002. In addition 12% of departments use traumatic Quincke needles which are associated with a higher incidence of postpuncture headache. Nitrous oxide is no longer frequently used in Germany. Finally, the administration of an antibiotic before cord clamping has been shown to lead to lower rates of endometritis and postoperative wound infection without detrimental effects on the newborn. This is practiced in only a small minority of departments across Germany.

Serosal penetration is an important prognostic factor for gastrointestinal stromal tumors.

Predicting the malignant potential of gastrointestinal stromal tumors (GISTs) remains difficult. We assessed the value of serosal penetration, an established prognostic factor in solid tumors, to determine the clinical outcome in patients with GISTs. From 1996-2002, 25 consecutive patients with GIST underwent surgical resection at our Department. The histopathological presence of serosal penetration was assessed to predict clinical outcome. In addition, the established histopathological classification system by Franquemont (modified by using the Ki-67 proliferation index), was applied to each study patient. A Ki-67 index > or =5% (p<0.001) and a mitotic rate > or =5/50 high-power fields (p<0.047) significantly correlated with a shorter survival, whereas a tumor size >5 cm (p=0.07) tended towards a worse prognosis. The survival of patient groups defined by Franquemont (p=0.03) were of prognostic relevance. The presence of serosal penetration significantly correlated (p<0.01) with a shorter survival. Our data suggest that the presence of serosal penetration is a negative prognostic factor for GISTs. Serosal penetration may become a useful additional parameter for the classification of the malignant potential of GISTs. Since our data are merely hypothesis-generating, serosal penetration should be evaluated in large prospective databases.

Comparative analysis of four histopathological classification systems to discriminate benign and malignant behaviour in gastrointestinal stromal tumors.

UNLABELLED: The prognostic value of the four most common histopathological classification systems in gastrointestinal stromal tumors (GISTs) was evaluated retrospectively. PATIENTS AND METHODS: Twenty-five consecutive patients with resected GIST and a follow-up of five years or more for surviving patients were included in this analysis. All the tumors were c-KIT (CD117) positive and were additionally re-evaluated for the number of mitoses per 50 high-power fields (HPF) and Ki-67 proliferation index. The four most commonly applied histopathological classification systems of the WHO, Franquemont (modified by using the Ki-67 proliferation index), Fletcher and Miettinen were applied to each patient. RESULTS: The survival of patient groups classified by Franquemont (p = 0.03) and the WHO (p = 0.031) were of prognostic relevance, while the grouping of patients by classifications according to both, Fletcher and Miettinen did not show a significant prognostic value. CONCLUSION: The classification systems of Franquemont (modified) or WHO appear to be advantageous for the evaluation of malignant potential and clinical outcome in patients with GISTs. Our data are merely hypothesis generating and should be validated in larger clinical studies.

Pain, postdural puncture headache, nausea, and pruritus after cesarean delivery: a survey of prophylaxis and treatment.

BACKGROUND: The need for a cesarean delivery may interfere negatively with the overall experience of childbirth. Several factors related to anesthesiological management such as postoperative pain and discomfort, nausea and pruritus, and postdural puncture headache (PDPH), may lead to dissatisfaction and have a negative impact on early mobilization and a new mother's ability to care for her newborn baby. Optimal prophylaxis and treatment decrease these complications, increase satisfaction, and prevent chronic pain. This survey determined how prophylaxis and treatment of pain, PDPH, nausea, and pruritus after cesarean section (CS) is managed. METHODS: A questionnaire was sent to 709 departments of anesthesiology serving an obstetric unit in Germany. The questionnaire asked about different aspects of pain management, the management of accidental dural puncture (ADP), and treatment of PDPH. Further we asked about therapy and prophylaxis of nausea and pruritus in the peripartal setting. RESULTS: In all, 360 questionnaires (50.8%) were returned; 346 were complete and analyzed (accounting for 330000 births per year). Paracetamol (77.5%) and piritramide (85.6%) are the most common analgesics used. If epidural catheters were used for anesthesia for CS, 47.7% were used for postoperative pain therapy. However, 92.7% of the departments removed catheters in less than 24 hours after delivery. In case of an ADP most departments (69.9%) repeated puncture, 2.6% placed catheters intrathecally. Median blood volume for an epidural blood patch was 10ml. CONCLUSION: Apart from conservative treatment of PDPH, prophylaxis and treatment of pain after cesarean delivery, PDPH, nausea, and pruritus varied widely, indicating the need for the qualitative evaluation of overall management.

Survey on the use of oxytocin for cesarean section.

BACKGROUND: The administration of oxytocin at high doses during cesarean section may cause severe cardiovascular complications. However, a dosage as low as 1 IU has been proven to suffice. Bolus administration is not superior to infusion and causes more severe side effects. The purpose of this survey was therefore to determine dosages and routes of administration of oxytocin during cesarean section in Germany. METHODS: A questionnaire was sent to 709 departments of anesthesiology. The questionnaire asked about the standard dosage of oxytocin and route of administration (bolus and/or slow infusion) used for cesarean section. RESULTS: A total of 360 questionnaires (50.8%) were returned; 346 of these were filled out and therefore analyzed (accounting for approximately 329,000 births). It was found that 295 (85.3%) departments administer oxytocin as a bolus, and 48 (13.9%) give it only as a slow infusion. A bolus of 1-3 IU is administered at 176 departments (51.8%), 5-9 IU at 71 (20.9%), 10 IU at 39 (11.6%), and 12-40 IU at 6 (1.8%). Additionally, 3-9 IU were slowly infused at 56 departments (16.7%), 10 IU at 174 (50.3%), 12-20 IU at 51 (14.7%), and 23-40 IU at 22 (6.4%). The median cumulative oxytocin dose is 13 IU, ranging from 1 to 80 IU. CONCLUSION: Most of the responding departments give oxytocin as a bolus at a relatively low dose. However, despite the potentially fatal side effects, one out of eight departments administers 10 IU or more as a bolus.