[Damage Control Resuscitation and Damage Control Surgery]. / Damage Control Resuscitation und Damage Control Surgery.

Trauma triggers complex physiological responses with primary and secondary effects vital to understanding and managing trauma impact. "Damage Control" (DC), a concept adapted from naval practices, refers to abbreviated initial surgical care focused on controlling bleeding and contamination, critical for the survival of severely compromised patients. This impacts anaesthesia procedures and intensive care. "Damage Control Resuscitation" (DCR) is an interdisciplinary approach aimed at reducing mortality in severely injured patients, despite potentially increasing morbidity and ICU duration. Current medical guidelines incorporate DC strategies.DC is most beneficial for patients with severe physiological injury, where surgical trauma ("second hit") poses greater risks than delayed treatment. Patient assessment for DC includes evaluating injury severity, physiological reserves, and anticipated surgical and treatment strain. Inadequate intervention can worsen trauma-induced complications like coagulopathy, acidosis, hypothermia, and hypocalcaemia.DCR focuses on rapidly restoring homeostasis with minimal additional burden. It includes rapid haemostasis, controlled permissive hypotension, early blood transfusion, haemostasis optimization, and temperature normalization, tailored to individual patient needs."Damage Control Surgery" (DCS) involves phases like rapid haemostasis, contamination control, temporary wound closure, intensive stabilization, planned reoperations, and final wound closure. Each phase is crucial for managing severely injured patients, balancing immediate life-saving procedures and preparing for subsequent surgeries.Intensive care post-DCS emphasizes stabilizing patients hemodynamically, metabolically, and coagulopathically while restoring normothermia. Decision-making in trauma care is complex, involving precise patient assessment, treatment prioritization, and team coordination. The potential of AI-based decision support systems is noted for their ability to analyse patient data in real-time, aiding in decision-making through evidence-based recommendations.

A case of recurring perioperative circulatory arrest: mind the autonomic nervous system.

We report the case of an elderly woman who developed recurring episodes of unexplained cardiocirculatory arrest. The index event appeared during surgery to fix a fracture of the ankle and consisted of bradypnea, hypotension and asystole, coherent with a Bezold-Jarisch-like cardioprotective reflex. Classical signs of acute myocardial infarction were absent. Yet, occlusion of the right coronary artery (RCA) was observed and successfully revascularized, whereupon circulatory arrests vanished. We discuss several differential diagnoses. Unexplainable circulatory failure, with sinus bradycardia and arterial hypotension, despite lack of ECG signs of ischemia or significant troponin levels, suggest the action of cardioprotective reflexes of the autonomic nervous system. Coronary artery disease is a common source. Attention to cardioprotective reflexes should be taken in the case of unexplained cardiac arrest without overt reasons. We recommend performing coronary angiography to exclude significant coronary stenosis.

[Anaesthetic Management of Non-intubated Video-assisted Thoracic Surgery]. / Anästhesie bei nicht intubierter videoassistierter Thoraxchirurgie (NiVATS).

Non-intubated thoracic surgery is currently gaining popularity. In select patients and in experienced centres, non-intubated approaches may enable patients to safely undergo thoracic surgical procedures, who would otherwise be considered at high risk from general anaesthesia. While non-intubated techniques have been widely adopted for minor surgical procedures, its role in major thoracic surgery is a topic of controversial debate.This article discusses disadvantages of intubated anaesthetic approaches and advantages of non-intubated thoracic surgery as well as the anaesthetic management. This includes surgical and anaesthetic criteria for patient selection, suitable regional anaesthetic techniques, concepts for sedation and maintenance of airway patency as well as the management of perioperative complications.Non-intubated thoracic surgery has the potential to reduce postoperative morbidity and hospital length of stay. Successful non-intubated management depends on a standardised and well-trained interdisciplinary approach, especially regarding patient selection and perioperative complications.

Dental Strain on Maxillary Incisors During Tracheal Intubation With Double-Lumen Tubes and Different Laryngoscopy Techniques - A Blinded Mannequin Study.

OBJECTIVES: To quantify dental forces during double-lumen tube intubations with different laryngoscopy techniques. DESIGN: Experimental biomechanical mannequin study. SETTING: Two German university hospitals. PARTICIPANTS: One hundred four anesthesiologists with varying levels of experience. INTERVENTIONS: Participants performed a sequence of intubations on a mannequin equipped with hidden forces sensors in the maxillary incisors. Different laryngoscopy techniques were evaluated under normal and difficult airway conditions. Direct laryngoscopy was compared with different videolaryngoscopy techniques: the C-MAC with a Macintosh blade, the GlideScope, and the KingVision with hyperangulated blades. MEASUREMENTS AND MAIN RESULTS: A total of 624 intubations were evaluated. In normal airway conditions, the median (interquartile range [range]) peak forces were significantly lower when the GlideScope (15.7 (11.3-22.0 [2.1-110.5]) N) was used compared with direct laryngoscopy (21.0 (14.1-28.5[4.7-168.6]) N) (p = 0.007). In difficult airways, resulting forces were reduced using hyperangulated videolaryngoscopes (GlideScope: -13.7 N [p < 0.001]; KingVision: -11.9 N [p < 0.001]) compared with direct laryngoscopy, respectively. The time to intubation was prolonged with the use of the KingVision (25.5 (17.1-41.9[9.2-275.0])s [p < 0.001]) in comparison to direct laryngoscopy (20.8 (15.9-27.4[8.7-198.6]) s). The C-MAC demonstrated the shortest time to intubation. CONCLUSIONS: Although hyperangulated videolaryngoscopes improve dental strain, clinicians also should consider the time to intubation, which is shortest with nonhyperangulated videoblades, when choosing a laryngoscopy technique on an individual patient basis.

Anesthesia for tracheal and carinal resection and reconstruction.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of current anesthetic management of tracheal and carinal resection and reconstruction. RECENT FINDINGS: In addition to the traditional anesthetic approach using conventional tracheal intubation after induction of general anesthesia and cross-field intubation or jet-ventilation once the airway has been surgically opened, there is a trend toward less invasive anesthetic procedures. Regional anesthetic techniques and approaches focusing on the maintenance of spontaneous respiration have emerged. Especially for cervical tracheal stenosis, laryngeal mask airways appear to be an advantageous alternative to tracheal intubation.Extracorporeal support can ensure adequate gas exchange and/or perfusion during complex resections and reconstructions without interference of airway devices with the operative field. It also serves as an effective rescue technique in case other approaches fail. SUMMARY: The spectrum of available anesthetic techniques for major airway surgery is immense. To find the safest approach for the individual patient, comprehensive interdisciplinary planning is essential. The location and anatomic consistency of the stenosis, comorbidities, the functional status of respiratory system, as well as the planned reconstructive technique need to be considered. Until more data is available, however, a reliable evidence-based comparison of different approaches is not possible.

Current practice of thoracic anaesthesia in Europe - a survey by the European Society of Anaesthesiology Part I - airway management and regional anaesthesia techniques.

BACKGROUND: The scientific working group for "Anaesthesia in thoracic surgery" of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery. METHODS: All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study. RESULTS: Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%). Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics. CONCLUSIONS: While certain "gold standards "are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe. Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety.

[Target Temperature Control in Patients with Burns]. / Zieltemperaturkontrolle beim Patienten mit Verbrennungen.

Severe burns lead to a persistent hypermetabolic response of the organism with significantly increased resting energy turnover, multi-organ dysfunction, muscle breakdown and increased risk of infection. Elevated core and skin temperatures are characteristic. A further increase in the metabolic rate can be triggered by heat losses, for which these patients are particularly predisposed due to high heat dissipation via evaporation of moisture and impairment of the thermoregulatory and insulating properties of the burnt skin. This is especially true in all treatment situations with exposure to large, uncovered skin surfaces, such as primary care, dressing changes in the intensive care unit and surgery with extensive sterile operating field. It has been shown that hypothermia is associated with numerous risks for the burn patient. Consistent heat management with measurement of the core body temperature and application of external and internal heat protection measures is recommended. Traditionally, an increase in room temperature is used here. However, this effective measure is limited by the resilience of the intensive care practitioners and the surgeons. To avoid perioperative hypothermia, strict surgical planning with limitation of the duration of surgery and close intraoperative communication about the risk of hypothermia are of particular importance.The differentiation between accepted temperature increase and infectious fever is often only possible by the inclusion of further examination findings. The criterion for sepsis is a temperature above 39 °C or below 36.5 °C.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study.

BACKGROUND: The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound. METHODS: We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax. RESULTS: We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population . CONCLUSIONS: Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions. TRIAL REGISTRATION: DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216.

Hypopharyngeal Perforation Mimicking Esophageal Atresia: A Case Report of an Extremely Low Birth Weight Infant Emphasizing the Need for Preoperative Endoscopy.

We report a case of an extremely low birth weight premature infant born at 27 weeks of gestation, transferred to our tertiary pediatric referral center for surgical repair of an esophageal atresia. Endoscopic evaluation before the start of surgery revealed a hypopharyngeal perforation, resulting in the false impression of esophageal atresia. If no tracheoesophageal fistula is found during tracheoscopy, esophagoscopy should be done before surgical intervention as the inability to pass a nasogastric tube into the stomach is not sufficiently reliable for a correct diagnosis of esophageal atresia.

Rapid and safe removal of foreign bodies in the upper esophagus in children using an optimized Miller size 3 video laryngoscope blade.

BACKGROUND: Foreign bodies lodged in the upper esophagus in children may result in life-threatening complications, especially with button batteries. Rapid removal is essential to prevent complications. Experts report that extraction with a suitable laryngoscope and a forceps is feasible under general anesthesia, but no further data had been available so far. AIMS: To study foreign body visualization and removal from the upper esophagus in children using a new optimized Miller size 3 blade video laryngoscope. METHODS: This prospective observational study was performed in three pediatric hospitals. The clinical observations were reported anonymously on an electronic spreadsheet after obtaining the informed consent from the parents or guardians. During the observational period from January 2019 to October 2020, all children with a foreign body lodged into the upper esophagus were eligible for participation and 22 cases were included. Main outcome measures were rates of successful removal and complications as well as duration of the procedure. Secondary outcome was subjective assessment regarding the quality of the visualization and the feasibility of the procedure. RESULTS: Success rate was 100% with no complications. Mean intervention and anesthesia times were 5 ± 4 minutes and 26 ± 25 minutes. Quality of visualization of the foreign body was judged as 'excellent' or 'good' in all cases and the feasibility of the procedure as 'without' or 'with little' effort in 95% of all cases. CONCLUSION: The new Miller size 3 video laryngoscope enables rapid, easy, and reliable extraction of foreign bodies when they are located in the upper part of the esophagus. As early removal of esophageal foreign bodies, especially with button batteries, prevents life-threatening complications, we suggest this technique as the first choice of treatment.

Post-thoracotomy pain syndrome: seldom severe, often neuropathic, treated unspecific, and insufficient.

BACKGROUND: Post-thoracotomy pain syndrome (PTPS) is reported with a prevalence ranging between 33% and 91% in literature. However, the difference between open (TT) and video-assisted thoracic surgery (VATS) concerning the prevalence and neuropathic character of PTPS has not yet been systematically investigated. Furthermore, knowledge on analgesic treatment and its efficacy is limited. METHODS: Structured telephone interviews were conducted with 488 patients 6 to 30 months after TT and VATS. In case of pain, patients received a structured questionnaire including the Leeds Assessment of Neuropathic Symptoms and Signs and Brief Pain Inventory. RESULTS: Prevalence of PTPS was 28.6%. 13.2% of patients had a pain intensity Numeric Rating Scale >3, and 4.6% of patients had a pain intensity Numeric Rating Scale >5. In case of PTPS, 63% of patients suffered from neuropathic pain. Post-thoracotomy pain syndrome was more frequent after TT than after VATS (38.0% vs 29.3%, P < 0.05) and in patients younger than 65 years (42.3% vs 26.4%; P < 0.05). TT resulted more often in neuropathic pain (67.7% vs 43.9%; P < 0.05). Forty six percent of PTPS patients received analgesics: 30.3% nonopioids, 25.2% opioids, 10.9% anticonvulsants, and 1.7% antidepressants. Antineuropathic agents were used in 17.4% of patients with neuropathic pain. In 36.7% of patients, the reported reduction of pain was less than 30.0%. CONCLUSIONS: Post-thoracotomy pain syndrome is not as common as estimated. In most cases, pain intensity is moderate, but patients suffering from severe pain require special attention. They are often heavily disabled due to pain. Tissue-protecting surgery like VATS is beneficial for the prevention of PTPS. Analgesic medications are often underdosed, unspecific for neuropathic pain, and insufficient.

Continuous lateral rotational therapy in thoracic trauma--A matched pair analysis.

INTRODUCTION: Given the lack of reliable evidence on the utility of continuous lateral rotational therapy (CLRT) in chest trauma, we performed a single-centre retrospective matched-pair analysis of patients treated either with CLRT or non-continuous manual turning after blunt thoracic trauma. METHODS: We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2-4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion. RESULTS: A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: -3.6; CLRT: -4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02). DISCUSSION: In this well-matched sample, the use of CLRT did not seem to translate into relevant clinical benefits in patients with thoracic trauma in the setting of modern ICU care with the widespread implementation of lung protective ventilation. However, statistical power and generalisability were limited by the small sample size and single centre design. A large RCT is required to provide conclusive results.

Sensitivity of chest ultrasound for postoperative pneumothorax in comparison to chest X-ray after lung resecting surgery.

OBJECTIVES: Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS: SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS: Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS: Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. CLINICAL TRIAL REGISTRATION NUMBER: DRKS-German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

Transglottic corticosteroid injection for treatment of soft post-intubation subglottic stenosis: a retrospective analysis of 26 children.

PURPOSE: Surgical treatment is generally recommended for severe subglottic lesions following traumatic endotracheal intubation in children. An alternative approach is early transglottic corticosteroid administration to reduce scar formation and prevent the need for subsequent surgical intervention. This technique has been practiced successfully for several decades at the Children's Hospital of Cologne and the outcomes of 26 subsequent patients reviewed in this analysis. METHODS: All patients who underwent transglottic corticosteroid injection for treatment of post-intubation stridor and dyspnoea between 2012 and 2018 were identified and their records and endoscopy images analysed. Severity of the endoscopic findings was assessed using the Myer-Cotton classification (MCC) and an Expected Need for Surgical Intervention (ENSI) score (1 = inevitable; 2 = very likely necessary; 3 = probably avoidable and 4 = most likely not necessary) was recorded. Treatment was considered successful if the children had a complete resolution of clinical symptoms. RESULTS: A total of 26 patients with a median (range) age of 1.9 (0.02-7.2) years and weight of 9.8 (1.8-25) kg were identified and included into the analysis. Endoscopic images were available for 22 children. All children underwent transglottic corticosteroid injection prior to any potential surgical treatment. A total of 22 patients (85%) improved following transglottic corticosteroid injection including 4 of 5 patients with a MCC = 3 and ENSI = 1 avoiding surgical intervention. None of the patients experienced a deterioration of clinical symptoms or endoscopic findings. CONCLUSION: Transglottic corticosteroid injections as first-line treatment in children with severe post-endotracheal intubation trauma can successfully resolve symptoms and prevent invasive surgery.

[Role of Procalcitonin as a Sepsis Marker]. / Stellenwert des Procalcitonins als Sepsismarker.

Adequate diagnosis and therapy of sepsis is of major prognostic relevance. Besides the gold standard (blood culture diagnostics) biomarkers, e.g. serum procalcitonin (PCT), are clinically increasingly used in the diagnosis and for guiding anti-infective treatment. Recent guidelines recommend early determination of PCT. However, trauma, burns, surgical procedure, and intoxications may significantly impact PCT levels. As a rare cause, PCT producing tumors have been described and may be potentially misleading in the clinical setting. While several other constellations for increased PCT in the absence of sepsis (e.g., trauma, intoxications) have been described, it needs to be summarized that according to currently available data, sensitivity and specificity for PCT for the diagnosis of sepsis in critically ill patients is on average between 70 and 80%. Thus, PCT must be interpreted carefully in the context of medical history, physical examination, and microbiological assessment. However, the existing body of literature emphasizes the value of PCT to shorten the duration of an antibiotic treatment. So far, different cut-off values for PCT for certain infections have been identified. While different treatment algorithms have been studied, PCT-guided treatment not only enables to reduce use of antibiotics but as shown most recently may improve outcome of critically ill patients.

Rationale and design of PASSAT - patients' satisfaction with local or general anaesthesia in video-assisted thoracoscopic surgery: study protocol for a randomised controlled trial with a non-randomised side arm.

BACKGROUND: Although general anaesthesia (GA) with one-lung ventilation is the current standard of care, minor thoracoscopic surgery, i.e. treatment of pleural effusions, biopsies and small peripheral pulmonary wedge resections, can also be performed using local anaesthesia (LA), analgosedation and spontaneous breathing. Whilst the feasibility and safety of LA have been demonstrated, its impact on patient satisfaction remains unclear. Most studies evaluating patient satisfaction lack control groups or do not meet psychometric criteria. We report the design of the PASSAT trial (PAtientS' SATisfaction in thoracic surgery - general vs. local anaesthesia), a randomised controlled trial with a non-randomised side arm. METHODS: Patients presenting for minor thoracoscopic surgery and physical eligibility for GA and LA are randomised to surgery under GA (control group) or LA (intervention group). Those who refuse to be randomised are asked to attend the study on the basis of their own choice of anaesthesia (preference arm) and will be analysed separately. The primary endpoint is patient satisfaction according to a psychometrically validated questionnaire; secondary endpoints are complication rates, capnometry, actual costs and cost effectiveness. The study ends after inclusion of 54 patients in each of the two randomised study groups. DISCUSSION: The PASSAT study is the first randomised controlled trial to systematically assess patients' satisfaction depending on LA or GA. The study follows an interdisciplinary approach, and its results may also be applicable to other surgical disciplines. It is also the first cost study based on randomised samples. Comparison of the randomised and the non-randomised groups may contribute to satisfaction research. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00013661 . Registered on 23 March 2018.

Successful treatment of abdominal compartment syndrome with chemotherapy in a patient with a newly diagnosed Burkitt lymphoma.

Mortality of patients treated on the intensive care unit suffering from cancer is high, especially when admitted with an unknown malignancy. Still, anti-tumor therapy in critically ill patients requiring mechanical ventilation is a clinical challenge. Over the last years, successful chemotherapy has been reported, even in critically ill patients with infections and organ failure. In this report, we present a 42-year old male patient who later was been diagnosed for a highly-malignant lymphoma (Burkitt) developed an abdominal compartment syndrome due to ileus, ascites and progressive intestinal tumor manifestation. During the course, he required mechanical ventilation and developed several organ failures including need for renal replacement therapy. After laparotomy the abdomen was left open and managed by a vacuum dressing. The patient received systemic chemotherapy and broad anti-infective treatment in presence of markedly elevated markers of inflammation. Fortunately, he was successfully weaned from vasopressor and respiratory support. By obtaining negative fluid balances closure of the abdomen succeeded 18 days after laparotomy. The patient was transferred to the normal ward without organ dysfunction on day 27 and discharged home after a second cycle of chemotherapy. In conclusion, aggressive treatment using chemotherapy in critically ill patients with initially unkown malignancy may be successful.

[Coffee, Cigarettes, Chewing Gum - Myths and Facts About Preoperative Fasting]. / Kaffee, Kippe, Kaugummi ­ Mythen und Fakten zur präoperativen Nüchternheit.

Consumption of clear liquids (including coffee and orange juice without pulp) up to 2 hours before the start of anaesthesia is unproblematic. Contrary to the recommendations of the professional societies, the intake of beverages containing milk (up to 50% of the total volume) in small quantities seems to be harmless. Drinks containing alcohol can considerably delay emptying of the stomach. Immediate preoperative nicotine consumption has no influence on the risk of aspiration, but short-term nicotine abstinence in patients with CHD can reduce the risk of intraoperative myocardial ischaemia. Chewing gum has no effect on the pH of gastric juice, but the gastric fluid volume is slightly increased. Cancelling surgery because of preoperative chewing of gum by a patient is not justified despite increased gastric fluid volume.

[Safe Paediatric Anaesthesia: Update on Drug Safety]. / Kinderanästhesie mit Sicherheit: Update Medikamentensicherheit.

Drug errors occur in all areas of care. Due to age-group-specific characteristics and the need for dose calculation, the probability of errors in children increases compared to adults. The recognition of the fallibility of every supplier and the acceptance of security structures are essential. The article describes a catalogue of measures for drug safety suitable for everyday use.