[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.

[Prone positioning of patients during venovenous extracorporeal membrane oxygenation is safe and feasible]. / Bauchlagerung von Patienten an der venovenösen ECMO ist möglich und sicher.

BACKGROUND: Prone positioning of patients with acute respiratory distress syndrome (ARDS) has been shown to significantly improve survival rates. Prone positioning reduces collapse of dorsal lung segments with subsequent reduction of alveolar overdistension of ventral lung segments, optimizes lung recruitment and enhances drainage. Patients with ARDS treated by extracorporeal membrane oxygenation (ECMO) can also benefit from prone positioning; however, the procedure is associated with a possible higher risk of serious adverse events. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of prone positioning for patients with severe ARDS during ECMO therapy. MATERIAL AND METHODS: This study involved a retrospective analysis of all patients placed in a prone position while being treated by venovenous ECMO (vvECMO) for severe hypoxemia in ARDS as bridge to recovery in the interdisciplinary intensive care unit at the University Hospital Leipzig between January 2009 and August 2013. Baseline data, hospital mortality and serious adverse events were documented. Serious adverse events were defined as dislocation or obstruction of endotracheal tube or tracheal cannula, ECMO cannulas and cardiac arrest. Prone positioning was carried out by at least one doctor and three nurses according to a standardized protocol. Results are given as the median (1st and 3rd quartiles). RESULTS: A total of 26 patients were treated with vvECMO as bridge to recovery due to severe ARDS. Causes for ARDS were pneumonia (n = 20) and aspiration (n = 2) and four patients had different rare causes of ARDS. The median time on ECMO was 8 days (6;11) and during this period 134 turning events were documented. Patients were proned for a median of 5 (3;7) periods with a median duration of 12 h (8;12). No serious adverse events were recorded. The hospital mortality was 42% and mortality during the ECMO procedure was 35%. CONCLUSION: Prone positioning significantly reduces the mortality of patients with severe ARDS. In this series of 26 patients with severe ARDS during ECMO therapy no serious adverse events were found during the use of prone positioning.

[Telephone enquiries on the topic of malignant hyperthermia: Evaluation of the content and subsequent diagnostic results at the MH Center Leipzig]. / Telefonische Anfragen zum Thema maligne Hyperthermie: Auswertung der Inhalte und der resultierenden Diagnostikergebnisse am MH-Zentrum Leipzig.

BACKGROUND: Malignant hyperthermia (MH) is an autosomal dominant metabolic myopathy. The in vitro contracture test (IVCT) is still considered to be the gold standard for diagnosing a disposition for MH. However, advances in genetic testing for MH disposition have supplemented or even replaced the invasive procedure of the IVCT. Information about MH can be obtained by either contacting the hotline for MH as a nationwide 24 h/7 days a week service or one of the regional MH centers. METHODS: The protocols of telephone conversations concerning MH at the MH Center University Leipzig were retrospectively analyzed. Data were collected from January 2011 to March 2015. Additionally, the results of the IVCT and genetic testing evolving from the counseling interviews were examined. RESULTS: A total of 205 telephone calls were documented during the period in question and an IVCT was performed as a consequence of 112 of the telephone calls. The IVCT resulted in 27 individuals being identified as MH susceptible which was subsequently diagnosed in 15 individuals with known familial MH disposition and 12 individuals were identified as new index patients. In 24 individuals a total of 13 different mutations were detected and of these 4 mutations were causative concerning MH. Of the 205 telephone calls 131 were private and 74 of medical professional origin. Among the private enquiries MH disposition within the family was a frequent reason for contacting the MH Center (61.8%). Conversations relating to MH-like symptoms during general anesthesia were carried out with 35.1% of medical doctors and with 22.9% of private callers. Advice about neuromuscular symptoms of unknown genesis was given to 15.3% of private individuals and to 24.3% of medical doctors. Overall MH topics were discussed with 23% (N = 17) of the medical profession and approximately half of these were anesthesiologists (N = 8). Not a single call was documented for the treatment of a suspected MH crisis. CONCLUSION: Private individuals and families affected by a MH disposition often showed good compliance with respect to counseling and diagnostics for MH and contacted the MH center more often than medical doctors. A more comprehensive cooperation with the medical profession is preferable and necessary to obtain a systematic and broad synopsis of characteristic and uncharacteristic signs and symptoms of MH. The telephone conversations analyzed as well as the diagnostic results (IVCT and genetic testing) underline that MH disposition is still a current and relevant topic.

[Clinical impact of infections with carbapenem-resistant enterobacteriaceae in liver transplant recipients]. / Klinische Bedeutung von Infektionen durch Carbapenem-resistente Enterobakterien bei Lebertransplantierten.

Infections with carbapenem-resistant Enterobacteriaceae (CRE) are an emerging cause of morbidity and mortality among liver transplant recipients (LTR) worldwide, particularly Klebsiella pneumoniae carbapenemase (KPC)-producing organisms. Approximately 3 - 13 % of solid organ transplant recipients in CRE-endemic areas develop CRE infections, and the infection site correlates with the transplanted organ. The cumulative 30-day mortality rate of LTR infected with carbapenem-resistant K. pneumoniae is 36 %, and the 180-day mortality rate is 58 %. Awareness of the high vulnerability of LTR to fatal bacterial infection leads to the more frequent use of ultrabroad-spectrum empirical antibiotic therapy, which further contributes to the selection of extreme drug resistance. Moreover, it comprises a relevant risk of failure to initiate adequate empirical treatment due to the fact that culture-based techniques used to identify CRE imply a 48- to 72-hour delay from blood culture collection until administration of the targeted therapy. This vicious circle is difficult to avoid and leads to increased clinical intricacy and narrowed antimicrobial therapeutic options. Because available options are extremely limited, infection prevention measures have gained outstanding importance, particularly in the phase after liver transplant requiring intense immunosuppression early on. Improving clinical outcomes is a major challenge and involves a multi-targeted approach combining strictly applied hygiene measures, active surveillance tests, the use of modern, time-saving methods of molecular biology, and enforced antibiotic stewardship. This article reviews the current literature regarding the incidence and outcome of CRE infections in LTR, and it summarises current preventive and therapeutic recommendations to minimise the threat by CRE in real-life clinical transplant settings.

[Perioperative evaluation and treatment of cardiovascular risk patients for noncardiac surgery : Guidelines of the European Society of Cardiology/European Society of Anaesthesiology 2014]. / Perioperative Beurteilung und Behandlung kardiovaskulärer Risikopatienten für nichtherzchirurgische Eingriffe : Leitlinien 2014 der European Society of Cardiology/European Society of Anaesthesiology.

In late summer 2014, the joint working group of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) presented new guidelines for the evaluation and treatment of cardiovascular risk patients undergoing noncardiac surgery. In addition to the preoperative collation of patient and intervention-specific risks, the guidelines deal with anaesthesiological and cardiological aspects of the perioperative management of patients with diseases of the heart and common comorbidities. This article summarizes the essential aspects of the guidelines in a clearly arranged form.

Colonization of liver transplant recipients with KPC-producing Klebsiella pneumoniae is associated with high infection rates and excess mortality: a case-control analysis.

PURPOSE: From mid-2010 to early 2013 there was a large single-center (Leipzig University Hospital, Germany) outbreak of Klebsiella pneumoniae carbapenemase (KPC) type 2 producing K. pneumoniae (KPC-2-KP) involving a total of 103 patients. The aim of this study was to compare KPC-positive liver transplant recipients (LTR) and KPC-negative controls to determine both the relative risk of infection following colonization with KPC-2-KP and the case fatality rate associated with KPC-2-KP. METHODS: The study cohort of this retrospective observational study comprised nine patients who had undergone orthotopic liver transplantation (LTx) (median age of 52 years, range 28-73 years) with confirmed evidence of colonization with KPC-2-KP. The data from these nine LTR were matched to 18 LTR (1:2) in whom carbapenem-resistant pathogens were not present and compared for clinical outcomes. RESULTS: Of these nine cases, eight (89 %) progressed to infection due to KPC-2-KP, and five (56 %) were confirmed to have bloodstream infection with KPC-2-KP. Matched-pair analysis of KPC-positive LTR and KPC-negative controls revealed a substantially increased relative risk of 7.0 (95 % confidence interval 1.8-27.1) for fatal infection with KPC-2-producing K. pneumoniae after transplantation with a mortality rate of 78 % (vs. 11 %, p = 0.001). CONCLUSIONS: Colonization with KPC-2-KP in LTR leads to high infection rates and excess mortality. Therefore, frequent screening for carbapenem-resistant bacteria in patients on LTx waiting lists appears to be mandatory in an outbreak setting. Patients with evidence of persistent colonization with KPC-producing pathogens should be evaluated with extreme caution for LTx.

[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]. / Interdisziplinäres Traumamanagement : Update 3 Jahre nach Implementierung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung.

BACKGROUND: The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM: This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS: In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS: The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION: The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

Prehospital airway management using the laryngeal tube. An emergency department point of view.

BACKGROUND: Competence in airway management and maintenance of oxygenation and ventilation represent fundamental skills in emergency medicine. The successful use of laryngeal tubes (LT, LT-D, LTS II) to secure the airway in the prehospital setting has been published in the past. However, some complications can be associated with the use of a laryngeal tube. METHODS: In a nonconsecutive case series, problems and complications associated with the use of the laryngeal tube in prehospital emergency medicine as seen by independent observers in the emergency room are presented. RESULTS: Various problems and possible complications associated with the use of a laryngeal tube in eight case reports are reported: incorrect placement of the laryngeal tube in the trachea, displacement and/or incorrect placement of the laryngeal tube in the pharynx, tongue and pharyngeal swelling with subsequently difficult laryngoscopy, and inadequate ventilation due to unrecognized airway obstruction and tension pneumothorax. CONCLUSION: Although the laryngeal tube is considered to be an effective, safe, and rapidly appropriable supraglottic airway device, it is also associated with adverse effects. In order to prevent tongue swelling, after initial prehospital or in-hospital placement of laryngeal tube and cuff inflation, it is important to adjust and monitor the cuff pressure. Article in English.

[Hepatorenal syndrome]. / Hepatorenales Syndrom.

Hepatorenal syndrome (HRS) is a unique form of acute renal failure occurring in patients with advanced cirrhosis or acute liver failure. In patients with ascites the incidence of HRS is 8 % and in end-stage liver disease 75 % of patients suffer from HRS. Vasodilation of splanchnic arteries with subsequent decrease of effective blood volume, arterial pressure and renal vasoconstriction is hypothesized to be the central pathophysiological mechanism leading to acute renal failure. Moreover, cardiac output might be decreased in advanced cirrhosis. There are two types of HRS: while HRS type 1 is characterized by a rapid progression to acute renal failure often triggered by a precipitating event, e. g. bacterial peritonitis, which can rapidly develop into multiorgan failure, HRS type 2 shows a more steadily or slowly progressive course to renal failure with increasing ascites. Type 1 HRS has the worst prognosis. Treatment options include pharmacological treatment with vasoconstrictors and albumin and placement of transjugular intrahepatic portosystemic shunts (TIPS) but can only partially improve the survival rate. Liver transplantation is the ultimate and only definitive treatment of patients with HRS.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]. / Polytrauma mit Beckenfraktur und schwerem Thoraxtrauma: Hat der Zeitpunkt der definitiven Beckenfrakturstabilisierung Einfluss auf den klinischen Verlauf?

BACKGROUND: The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function. METHODS: A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay. RESULTS: The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01). CONCLUSIONS: In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

[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.

[Targeted temperature management in critical care : current 2011 recommendations]. / Gezieltes Temperaturmanagement auf der Intensivstation : Aktuelle Empfehlungen 2011.

Since October 2011 new guidelines exist for temperature management in critical care. According to the guidelines the term targeted temperature management (TTM) should replace the term therapeutic hypothermia. There is now a strong recommendation for TTM using 32-34°C as the preferred treatment for out-of-hospital adult cardiac arrest with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation. A TTM of 32.5-35.5°C is also recommended for the treatment of term newborns who sustain asphyxia and exhibit acidosis and/or encephalopathy.

[Real-time 3 dimensional full volume data set : benefits in problem focused intraoperative transesophageal echocardiography]. / "Real-time-3-dimensional-full-volume"-datensatz : nutzen in der problemfokussierten intraoperativen transösophagealen echokardiographie.

BACKGROUND: Comprehensive intraoperative transesophageal echcardiography (TEE) includes various measurements for quantification of cardiac chambers and valves based on multiple two dimensional (2D) standard views. Due to shortness of time during cardiac surgery most centres in Germany only carry out problem focussed intraoperative examinations which does not allow the complete repertoire of measurements to be exhausted. The aim of this study was to investigate which measurements for cardiac chamber and valve quantification can be performed with the acquisition of a real-time 3D full volume (RT-3D-FV) data set and to compare these measurements with those based on standard 2D views. MATERIALS AND METHODS: In patients undergoing elective surgical mitral valve repair a comprehensive 2D TEE examination according to the guidelines of the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) was performed after induction of anesthesia. Additionally, a RT-3D-FV TEE data set based on the midesophageal four chamber view was recorded (iE 33, Philips, Netherlands). All measurements of the 2D TEE and the RT-3D-FV dataset (Qlab) were performed offline by two independent examiners. RESULTS: After approval by the local ethic committee and obtaining written informed consent 50 patients (31 male and 19 female) with a mean age of 59.4 ± 11.5 years were enrolled in this study. All measurements recommended for chamber and valve quantification could be performed on the basis of the RT-3D-FV data set except for measurements of the sinus of Valsalva and the sinotubular junction. There was good correlation between the results of the two methods. CONCLUSIONS: For intraoperative problem focussed TEE examinations the acquisition of an additional RT-3D-FV TEE data set allows accurate measurement of most of the recommended chamber and valve quantification parameters.

[Burnout in anesthesiology and intensive care : is there a problem in Germany?]. / Burn-out in der Anästhesie und Intensivmedizin : Gibt es ein Problem in Deutschland?

BACKGROUND: With the demands faced by anesthetists and intensive care physicians apparently increasing continuously in Germany, the increased risk of burnout in comparison with the general working population is discussed. This debate has previously been merely speculative because of the lack of studies comparing the burn-out risk of the German working population with anesthetists. Accordingly it was not certain whether anesthetists really are at greater risk of developing burnout as has often been suggested. Moreover, age, gender, function, workplace environment, e.g. working at a hospital compared to a general practitioner (GP) surgery, may influence the risk of burnout. Therefore, this study examined whether the risk for anesthetists in Germany suffering from burnout really is greater than in other occupations. In addition, factors influencing the burnout risks of anesthetists were analyzed. METHOD: A total of 3,541 questionnaires completed by German aaesthetists for a study on work satisfaction by the CBI (Copenhagen Burnout Inventory, part of the Copenhagen Psychosocial Questionnaire, COPSOQ) were analyzed. Apart from calculating the number of participants with a high risk of developing burnout syndrome, the data were used to calculate a generalized burnout score for all participants. The score was compared with data from both a random sample representing a wide variety of occupations from among the general population in Germany (n = 4,709) and a random sample of German hospital doctors (n = 616). In addition, subgroups were formed by gender, function (senior consultant, senior physician, specialist, junior doctor) and type and place of work (university hospital, public hospital, private clinic, GP surgery, freelance work) and the proportion of each group with a high risk of burnout syndrome was calculated. In addition, general burnout scores were compared statistically for differences among the various groups. RESULTS: The proportion of study participants with a high risk of burnout was 40.1%. Differences were found to exist between genders (male 37.2% versus female 46%), qualifications (senior consultant 28.9%, senior physician 38%, specialist 41.5%, junior doctor 46.7%) and working in a hospital (41.3%) compared to a GP surgery (33.2%). The random sample of hospital doctors (n = 616) showed a burnout score of 49 ± 19 (mean ± standard deviation), compared to 44 ± 19 for a random sample of the German population (n = 4,709) and 42 ± 19 for anesthetists (p < 0.01). Of the subgroups formed, the highest score (49.1 ± 19) was recorded for female junior doctors working in anesthesia. The type of hospital did not influence the burnout score (university hospital 43.8 ± 19.8 versus public hospital 42.9 ± 19.1 versus private hospital 42.4 ± 18.7, p > 0.05). Working in a hospital was found to result in higher burnout scores than in a GP surgery or freelance work (43 ± 19.2 versus 38.1 ± 20.5; t(3531) = 5.0, p < 0.001) CONCLUSIONS: Despite 40.1% of anesthetists being at high risk of burnout, generally speaking the risk of burnout among anesthetists was not higher than in other occupational groups in Germany. However, burnout risks for specific groups, such as female junior doctors in anesthesia, were higher and the possibility of providing social support in the workplace should be considered.

[The significance of perioperative immunonutrition]. / Stellenwert der perioperativen Immunonutrition.

Perioperative immunonutrition is aiming at modulating altered immunological and metabolic functions in the context of major surgery. It is defined as the supplementation of constitutionally essential substrates such as glutamine, arginine, omega-3-fatty acids or nucleotides. The application of such formula is recommended for patients undergoing major abdominal-surgical procedures and tumour surgery in the head neck area. The substitution should be given 5-7 days before and after the intervention.

Pharmacokinetics and clinical toxicity of prilocaine and ropivacaine following combined drug administration in brachial plexus anesthesia.

OBJECTIVE: Local anesthetics (LA) are often administered in combination for regional anesthesia in order to obtain the specific advantages (onset and duration of effect) of each drug. However, few data on the safety of such combinations are available and consequently plasma concentrations possibly associated with toxicity and interactions between the specific anesthetics are not sufficiently established. We measured pharmacokinetics and toxicity parameters of prilocaine and ropivacaine after combined use as single doses in brachial plexus blockade. METHODS: In an open clinical study using a combined dose regime (300 mg prilocaine followed immediately by 75 mg ropivacaine) total plasma concentrations of prilocaine and ropivacaine were measured serially in 60 patients using a gas-chromatographic method. The data were analyzed regarding a relationship with central nervous and cardiovascular toxicity. RESULTS: Following the administration in combination prilocaine and ropivacaine were rapidly absorbed. Mean prilocaine peak plasma concentrations (mean Cmax = 1.51 microg/ml) were measured between 15 and 30 min after injection. Highest ropivacaine plasma concentrations (mean Cmax = 1.12 microg/ml) were seen between 30 min and 1 hour after injection (calculated mean tmax = 44 min). One of 59 patients showed signs of myoclonus which were suspected of being due to intravascular injection. There was no relevant cardiovascular toxicity observed in terms of changes in the QRS complex, PQ interval prolongation, AV dissociation, occurrence of extrasystoles or sinus arrest. The pharmacokinetics of combined administration did not differ from those of prilocaine and ropivacaine given alone. CONCLUSION: The use of a combined prilocaine/ ropivacaine (300 mg/75 mg) dose regimen in patients given single dose for brachial plexus blockade can generally be regarded as safe with regard to peak plasma concentrations and cardiovascular toxicity and this holds true for patients with a higher perioperative risk profile (ASA III grading, American Society of Anesthesiologists). The considerable inter-individual variation in LA peak plasma concentrations observed in our patients and the one case of suspected accidental intravascular injection, highlight the necessity of adequate monitoring of the patients undergoing LA injections.