[Nonoperating room anesthesia]. / Dezentrale Arbeitsplätze in der Anästhesiologie.

Anesthesia services outside central surgical facilities (nonoperating room anesthesia, NORA) have become more important. Nonoperating room anesthesia is a challenging field with a wide range of patient ages and interventions. The anesthesiologist is caught between the existing expertise in sedation, respiratory and emergency management and the fact that it may be a potentially avoidable cost factor. The efforts of some specialist departments to carry out sedation themselves even with more complex interventions have therefore increased. In order to permanently establish anesthesia here, apart from the pure anesthesiological expertise, a pronounced willingness to interdisciplinary communication and cooperation is necessary. Only in this way can the participating specialist disciplines be convinced of the anesthesiological added value for the patient. Groups of patients requiring special attention include pediatric patients. The care especially for children under 2 years old also requires the particular anesthesiological expertise of the supervising anesthesiologist; however, profound knowledge, for example in cardiac anesthesia, is also required if special interventions are decentrally managed in the cardiac catheterization laboratory.

[Influence of social characteristics on the duration of treatment, severity of the disease and social support of patients in a surgical intensive care unit]. / Einfluss sozialer Charakteristika auf die Behandlungsdauer, Erkrankungsschwere und soziale Unterstützung von Patienten einer operativen Intensivstation.

BACKGROUND: In critical illnesses low socioeconomic status (SES) is associated with higher morbidity and mortality. In addition to the SES, further factors at an individual level (e.g., sex, health insurance status and place of residence) may influence the severity of illness and medical treatment. We investigated these additional parameters in a secondary analysis of the ECSSTASI data. METHODS: Within the framework of the ECSSTASI study, 996 patients were recruited from a surgical intensive care unit. We examined the influence of sex, insurance status and place of residence on health-related behavior, disease severity, duration of intensive care and ventilation (28 ventilator-free days score, 28-VFDS) and social support by the next of kin. Multivariate-adjusted logistic regression analyses were carried out and odds ratios (OR) are presented with corresponding 95% confidence intervals. RESULTS: Among patients admitted to the intensive care unit, the disease severity (SOFA score >5) was significantly lower in women than in men (OR 0.62 [0.45-0.87]). Increasing size of the patient's town of residence was associated with a significantly shorter duration of treatment on the intensive care unit (OR 0.54 [0.32-0.91]). An increasing number of persons in the household was associated with a significantly increased risk of being ventilated longer compared to 1­person households (p = 0.028). Patients with private insurance (OR 1.87 [1.28-2.70]), patients from households with ≥4 persons (OR 1.92 [1.1-3.33]) and patients without German citizenship (OR 2.56 [1.39-4.55]) were visited significantly more often by next of kin. CONCLUSION: In addition to the SES, sociodemographic characteristics of the individual patient are associated with the course of treatment in intensive care medicine. The extent of social support by the next of kin depends on intercultural and individual patient characteristics. An increasing size of the town of residence and private health insurance status positively influence intensive care outcomes. In order to evaluate these data, further epidemiological studies in intensive care medicine are necessary.

[Outpatient palliative medicine : Attitudes in the care of palliative emergencies. Prospective questionnaire-based investigation]. / Ambulante Palliativmedizin : Einstellungen in der Versorgung palliativer Notfälle. Prospektive Fragebogenuntersuchung.

BACKGROUND: The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations. METHODS: A standardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions. RESULTS: The survey response rate was 79% from a total of 81 SPCS in 2011. The following standards in palliative emergency care were recommended: (1) early integration of outpatient palliative care services and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4) emergency medical training (physicians and paramedics). CONCLUSION: Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.

Performance of a new-generation continuous autotransfusion device including fat removal and consequences for quality controls.

BACKGROUND AND OBJECTIVES: Cell salvage plays a key role in blood conservation. To maintain high performance, quality management is recommended. Accordingly, a new-generation autotransfusion device was tested for its performance and compared with its predecessor. Two different calculations of quality parameters were applied. MATERIALS AND METHODS: In an experimental study, the continuous autotransfusion devices CATSmart and Continuous Autotransfusion System (C.A.T.S) plus were tested using banked blood adjusted to a haematocrit of 20% and anticoagulated with heparin 5 U/L. Test blood was processed using an emergency programme, a high-quality programme/smart wash programme and a low-volume wash programme. Samples were taken after the production of 200 mL of red blood cells (RBC) and after the final emptying of the separation chamber. In an additional set of tests, blood containing 1·25% fat was processed with both devices to examine fat removal. RESULTS: Both devices demonstrated an equally high performance with regards to product hematocrit (Hct); RBC recovery; and elimination rates of protein, heparin and fat. The high fat elimination rate (>99·8%) reported for C.A.T.S plus was confirmed for CATSmart, regardless of the used programme. Samples taken during the ongoing process show a higher haematocrit and RBC recovery rate than samples taken after the final emptying of the separation chamber. Interface sensors were not affected by fat in the blood. CONCLUSIONS: The new-generation autotransfusion device CATSmart is not inferior to its predecessor and shows high performance with regards to RBC recovery, plasma and fat elimination in all programme modes. Samples for quality controls should be taken during blood processing.

[Use of near-infrared spectroscopy for control of limb perfusion during venoarterial ECMO treatment : Application and limitations]. / Verwendung der Nahinfrarotspektroskopie zur Kontrolle der Extremitätenperfusion unter venoarterieller ECMO-Therapie : Einsatz und Limitationen.

Patients undergoing peripheral venoarterial extracorporeal membrane oxygenation have a high risk of lower limb ischemia. In general, regular controls are carried out based on clinical and laboratory parameters in order to quickly detect and treat complications. These controls are challenging due to states of shock, nonpulsatile flow and vasopressor therapy. As additional monitoring the use of near-infrared spectroscopy (NIRS) is described in the literature as being very successful in detecting ischemia. The present article describes the use and possible limitations of NIRS for the diagnostics of peripheral ischemia.

Effects of ropivacaine, bupivacaine and sufentanil in colon and pancreatic cancer cells in vitro.

The perioperative period is supposed to be a vulnerable period for cancer progression. Results of clinical studies indicate that the use of regional anesthesia can influence and improve oncological outcome of cancer patients. Uncontrolled cell proliferation and resistance to apoptotic cell death are important characteristics of solid tumors. The aim of this study was to investigate the effects of the clinically used local anesthetics ropivacaine or bupivacaine and the opioid analgesic sufentanil on cell proliferation, cell cycle distribution and apoptosis of colon (HT 29 and SW 480) and pancreatic (PaTu 8988t and PANC 1) cancer cell lines in vitro. Cell proliferation was measured by Cell Proliferation ELISA BrdU Assay. Apoptosis was analyzed by annexin V staining and cell cycle distribution was detected by flow cytometry. Ropivacaine, bupivacaine and sufentanil did not change apoptosis rate and cell cycle distribution in clinically concentration. Only high concentrations of ropivacaine or bupivacaine revealed antiproliferative potency. Protective effects of epidural anesthesia observed in clinical studies seem not to be based on direct effects of these drugs on cancer cells.

[Assessment of the transplantation scandal by the media : scientific discourse analysis of selected German newspapers]. / Wertungen des "Transplantationsskandals" durch die Medien : Diskursanalytische Studie an ausgesuchten deutschen Zeitungen.

BACKGROUND: The press is an important medium and plays a significant role as an information source for people. Moreover, the daily press transmits opinion-forming contents. During the German "transplantation scandal" various articles were published in the German press focusing on organ donation, transplantation, allocation of organs and brain death determination. Selected important newspaper articles were analyzed using a scientific text analysis as it was assumed that the publications might have had an important influence on attitudes or mistrust of transplantation medicine. MATERIAL AND METHODS: A total of 216 articles from Süddeutsche Zeitung, Die Welt, Frankfurter Allgemeine Zeitung and Die Zeit published between summer 2012 and early 2013, which focused on the transplantation scandal were analyzed using a modern form of scientific text analysis. From these articles 12 categories of contents were identified which were analyzed quantitatively and qualitatively. RESULTS: Most articles were published between June and August 2012 when the accusations of organ allocation manipulation were made public. A second wave was found in the early months of 2013, when the court proceedings against the predominantly blamed physician began. Most of the categories (63.8 %) transmitted a negative evaluative opinion (i.e. loss of confidence, enrichment of the persons involved, fraud, misconduct, rejection of brain death and disturbing the peace of the dead) leading to mistrust of transplantation per se, while the minority (36.2 %) were categorized as endeavoring to convey objective information, focus on ethical responsibility for organ donation or the problems of organ shortage. Furthermore, a striking increase of articles doubting the concept of brain death was observed. CONCLUSION: German newspapers as important opinion-leading and opinion-forming media have a substantial impact in accomplishing the demands for objective and factual information of transplantation medicine. Physicians, ethicists, journalists and politicians are invoked to have a closer collaboration in the future.

[Patients with implanted ventricular assist devices : Challenge for emergency medicine]. / Patienten mit implantierten Herzunterstützungssystemen : Herausforderung in der Notfallmedizin.

Due to a huge increase in the implantation of ventricular assist devices (VAD) over the last few years and the enormous technical advances in functional safety, a growing number of patients with VAD are discharged from hospital, who are still considered to be severely ill. This results in an increased probability of these patients interacting with emergency services where personnel are unaware of the presence of a VAD, creating anxiety and uncertainty regarding how to treat these patients. This article presents an overview of the most common problems and pitfalls regarding VADs. It also presents an algorithm for dealing with emergencies involving these patients including the diagnostics, treatment and primary transport.

[Anesthesia management in implantation of baroreceptor stimulators]. / Anästhesiologisches Management bei Implantation von Barorezeptorstimulatoren.

Baroreceptor stimulators are novel implantable devices that activate the carotid baroreceptor reflex. This results in a decrease in activity of the sympathetic nervous system and inhibition of the renin-angiotensin-aldosterone system. In patients with drug-resistant hypertension, permanent electrical activation of the baroreceptor reflex results in blood pressure reduction and cardiac remodeling. For correct intraoperative electrode placement at the carotid bifurcation, the baroreceptor reflex needs to be activated several times. Many common anesthetic agents, such as inhalation anesthetics and propofol dampen or inhibit the baroreceptor reflex and complicate or even prevent successful placement. Therefore, a specific anesthesia and pharmacological management is necessary to ensure successful implantation of baroreceptor reflex stimulators.

[Simulation as possible training for palliative emergencies: prospective initial data analysis of participants from two simulation training sessions]. / Simulation als Möglichkeit zum Training palliativer Notfälle : Prospektive erste Datenanalyse von Teilnehmern zweier Simulationstrainings.

BACKGROUND: Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. AIM: This article presents the preparation of recommendations in the training and development of palliative care emergency situations. MATERIAL AND METHODS: A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. RESULTS: Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. CONCLUSION: The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Lipid emulsion pretreatment has different effects on mepivacaine and bupivacaine cardiac toxicity in an isolated rat heart model.

BACKGROUND: The use of lipid emulsions to reduce cardiac toxicity of local anaesthetics (LAs) has shown success in experimental studies and some clinical cases, and thus has been implemented in clinical practice. However, lipid treatment is usually given after the occurrence of neurological or cardiovascular symptoms of systemic intoxication. The aim of this study was to determine if pretreatment with lipid emulsion reduces cardiac toxicity produced by bupivacaine or mepivacaine. METHODS: Isolated rat hearts were perfused with or without lipid emulsion (0.25 ml kg(-1) min(-1)) before administration of equipotent doses of bupivacaine (250 µM) or mepivacaine (1000 µM). Haemodynamic parameters and times from start of perfusion LA to a 1 min period of asystole and recovery were determined. RESULTS: Pretreatment with lipid emulsion extended the time until occurrence of asystole and decreased times to recovery in bupivacaine-induced cardiac toxicity but not in mepivacaine-induced cardiac toxicity compared with control. Lipid pretreatment impaired rate-pressure product recovery in mepivacaine-intoxicated hearts. CONCLUSIONS: This study confirms that pretreatment with a lipid emulsion reduces cardiac toxicity of LAs. The efficacy of pretreatment with lipid emulsion was LA-dependent, so pharmacokinetic properties, such as lipophilicity, might influence the effects of lipid emulsion pretreatment.

[Malignant hyperthermia]. / Maligne Hyperthermie.

Malignant hyperthermia (MH) is a rare hereditary, mostly subclinical myopathy. Trigger substances, such as volatile anesthetic agents and the depolarizing muscle relaxant succinylcholine can induce a potentially fatal metabolic increase in predisposed patients caused by a dysregulation of the myoplasmic calcium (Ca) concentration. Mutations in the dihydropyridine ryanodine receptor complex in combination with the trigger substances are responsible for an uncontrolled release of Ca from the sarcoplasmic reticulum. This leads to activation of the contractile apparatus and a massive increase in cellular energy production. Exhaustion of the cellular energy reserves ultimately results in local muscle cell destruction and subsequent cardiovascular failure. The clinical picture of MH episodes is very variable. Early symptoms are hypoxia, hypercapnia and cardiac arrhythmia whereas the body temperature rise, after which MH is named, often occurs later. Decisive for the course of MH episodes is a timely targeted therapy. Following introduction of the hydantoin derivative dantrolene, the previously high mortality of fulminant MH episodes could be reduced to well under 10 %. An MH predisposition can be detected using the invasive in vitro contracture test (IVCT) or mutation analysis. Few elaborate diagnostic procedures are in the developmental stage.

[Interaction of anesthetics and analgesics with tumor cells]. / Interaktion von Anästhetika und Analgetika mit Tumorzellen.

The results of preclinical and clinical studies indicate that the perioperative period is a vulnerable period for cancer progression and metastasis. The risk of cancer cell dissemination is enhanced by the combination of surgical manipulation and perioperative immunosuppression. Whether the oncological outcome of cancer patients can be influenced by the choice of anesthetic techniques is still a matter of debate. This review summarizes the molecular characteristics of cancer and interaction of anesthetic and analgesic drugs with cancer cells.

Thromboelastometric detection of clotting Factor XIII deficiency in cardiac surgery patients.

AIM(S): In this article, we aimed to investigate plasma Factor XIII levels after extracorporeal circulation in cardiac surgery by thromboelastometric detection, as extracorporeal circulation causes various coagulation disorders due to the exposure of blood to artificial surfaces, inflammatory induction and mechanical destruction of platelets and coagulation factors, which may particularly affect factors with long half-lives, such as Factor XIII. BACKGROUND: Since transfusion algorithms are often empirical and laboratory analysis of Factor XIII plasma levels may not be available 24 h a day, bed-side testing using rotational thromboelastometry (ROTEM) could offer a splendid option to define the cause of excessive peri-operative bleeding disorders in general and Factor XIII levels in particular in a timely manner and thus facilitating exact substitution therapy. METHODS: In this trial, we investigated 25 cardiac surgery patients with extracorporeal bypass times over 100 min. Standard laboratory and ROTEM analyses were performed post-operatively at the time of intensive care unit admission and 6 h later. We implemented EXTEM with additional Factor XIII (teenTEM) as additional test by adding 0·625 IU Factor XIII to standard EXTEM reagents. RESULTS: In this observational study, we could not demonstrate a correlation between Factor XIII and MCFEXTEM , CFTEXTEM or MLEXTEM . Neither Factor XIII plasma levels nor MCFEXTEM could predict blood loss. In accordance with previous findings, we were able to demonstrate increased maximum clot firmness (MCF), decreased clot formation time and decreased maximum lysis by adding Factor XIII in vitro (teenTEM vs EXTEM) indicating an improvement in the coagulation process. As shown before, we also found a strong correlation between MCF and platelet and fibrinogen plasma levels. CONCLUSION: In summary, 'teenTEM' test does not seem to detect Factor XIII deficient patients in cardiac surgery. Furthermore, post-operative blood loss could not be predicted neither by ROTEM nor by laboratory analysis of Factor XIII. In vitro administration of Factor XIII appears to improve laboratory measures of haemostasis.

[Successful infection control in regional anesthesia procedures: observational survey after introduction of the DGAI hygiene recommendations]. / Erfolgreiche Infektionskontrolle bei Regionalanästhesieverfahren: Verlaufsbeobachtung nach Einführung der DGAI-Hygieneempfehlungen.

BACKGROUND: In the context of regional anesthesia procedures adverse events rarely occur but are predominantly systemic intoxication due to local anesthetics (0.01-0.035 %), nerve injuries (0.01-1.7 %) and infections (0-3.2 %). MATERIALS AND METHODS: In a level 1 trauma centre data from all continuous peripheral nerve blocks (cPNB) were prospectively acquired over a period of 8 years (2002-2009) in an observational study (n = 10,549). The acquisition of data was carried out in an intranet-based data bank which was accessible for 24 h on every anesthesia workstation. The collected data included type of block, catheter duration and accompanying complications. This study was carried out with special respect to infectious complications (inflammation and infection). RESULTS: In the years 2002-2004 unexpectedly high rates of infectious complications were observed in 3,491 cPNBs with 146 inflammations (4.2 %) and 112 infections (3.2 %). Based on these alarming findings the existing hygiene regime was revised. The innovations were incorporated into the "Hygiene recommendations for the initiation and continued care of regional anaesthetic procedures" of the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI). A major change was the extension of skin disinfection to a spray-and-scrub combined procedure lasting 10 min. The introduction of this care bundle was carried out in 2005. Among 7,053 cPNBs that were conducted between 2005 and 2009 inflammation occurred in only 183 procedures (2.6 %) and infection in 61 procedures (0.9 %). This reduction was highly significant in both categories (p < 0.001). The risk factors catheter duration and catheter localization statistically remained unchanged during the observational period CONCLUSION: Using a real-time computer-based tool for data capture makes a veritable detection of adverse events possible. Such a tool also has the power to monitor the effects of changes in clinical procedures (SOP). In this case it was possible to verify the successful introduction of an extended hygiene care bundle. The new regime significantly decreased the rate of infections in cPNB.

[Peripheral regional anesthesia in patients under general anesthesia: risk assessment with respect to parasthesia, injection pain and nerve damage]. / Periphere Regionalanästhesie beim Patienten in Allgemeinanästhesie : Risikobewertung bezüglich Parästhesie, Injektionsschmerz und Nervenschäden.

Nerve injury after peripheral regional anesthesia is rare and is not usually permanent. Some authors believe that inducing peripheral nerve blocks in patients during general anesthesia or analgosedation adds an additional risk factor for neuronal damage. This is based on published case reports showing that there is a positive correlation between paresthesia experienced during regional anesthesia and subsequent nerve injury. Therefore, many sources recommend that regional nerve blocks should only be performed in awake or lightly sedated patients, at least in adults. However, there is no scientific basis for this recommendation. Furthermore, there is no proof that regional anesthesia performed in patients under general anesthesia or deep sedation bears a greater risk than in awake or lightly sedated patients. Currently anesthesiologists are free to follow personal preferences in this matter as there is no good evidence favoring one approach over the other. The risk of systemic toxicity of local anesthetic agents is not higher in patients who receive regional anesthesia under general anesthesia or deep sedation. Finally, in children and uncooperative adults the administration of peripheral nerve blocks under general anesthesia or deep sedation is widely accepted.

[Anesthesiological acute pain therapy in Germany: telephone-based survey]. / Anästhesiologische Akutschmerztherapie in Deutschland: Telefonbasierte Umfrage.

INTRODUCTION: The last survey of anesthesiological acute pain therapy in Germany was conducted in 1999. Since then new organisational as well as therapeutic aspects have developed. Amongst others the operation and procedures key (OPS) figure 8-919 complex acute pain therapy has been introduced in the German medical billing system, with the restriction that it cannot currently be redeemed. There is an ongoing debate on the role of epidural analgesia in acute pain therapy and new oral medication concepts have been established. Therefore a survey of the present state of acute pain therapy in Germany was conducted. METHODS: Based on a list of all 1,356 hospitals in Germany a randomized list of 412 hospitals was generated. Out of these 412 hospitals those with anesthesiology departments (378 hospitals) were contacted via telephone and asked to participate in the survey. Out of the 378 hospitals 285 (75.4 %) agreed to take part. The survey consisted of a questionnaire containing closed and open questions regarding organisational and therapeutic aspects of acute pain therapy. The ethics committee of the University of Regensburg rated the survey as not being subject to approval due to the lack of personal patient data. RESULTS: Of the participating hospitals 183 (64.2 %) had an acute pain service (APS) and of these 107 (58.5 %) met the quality criteria of the OPS 8-919. This figure however, was only consistently documented by 40 (37 %) APSs. Epidural analgesia (EA) was offered by 275 (96.5 %) hospitals and patient-controlled intravenous analgesia (PCA) by 255 (89.5 %). Likewise, 255 (89.5 %) hospitals used controlled-released opioids in acute pain therapy. Concerning EA, the medications most used were sufentanil as an opioid and ropivacaine as a local anesthetic in255 (92.7 %) of the hospitals with EA for sufentanil and 253 (92 %] for ropivacaine. An EA was offered on regular wards in 240 (87.3 %) hospitals. Uncertainty existed about concrete limits for coagulation values before removal of an epidural catheter. The opioid most utilized in PCA was piritramide with some hospitals using morphine or oxycodone (92.2 %, 9.4 % and 9.4 %, respectively). Other opioids, such as hydromorphone and tramadol were rarely used and remifentanil was not used at all. Oral medication was widely used with metamizole being the non-opioid analgesic and oxycodone/naloxone the controlled-release opioid being prescribed the most. New antiepileptic drugs, such as gabapentin or pregabalin were rarely employed in acute pain therapy. CONCLUSIONS: Since 1999 the number of hospitals that have implemented an APS has risen from 36.1 % to 64.2 %. The lack of consistent documentation of the OPS 8-919 will probably not increase the likelihood that it will become redeemable in the near future. Certain therapy methods, such as EA and PCA were still well established with oral therapy gaining in significance. The uncertainty regarding limits for coagulation values before removal of an epidural catheter could perhaps be reduced by a statement from the German Society of Anesthesia and Intensive Care.

[Perioperative care of palliative patients by the anesthetist : medical, psychosocial and ethical challenges]. / Perioperative Betreuung von Palliativpatienten durch den Anästhesisten : Medizinische, psychosoziale und ethische Herausforderungen.

Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.

[Interprofessional education in pain management: development strategies for an interprofessional core curriculum for health professionals in German-speaking countries]. / Interprofessionelle Lehre in der Schmerzmedizin : Möglichkeiten und Strategien für die Entwicklung eines professionsübergreifenden Curriculums im deutschsprachigen Raum.

The care of patients, suffering from acute, chronic, or malignant pain, requires systematic and interprofessional collaboration between all team members to ensure a holistic approach to pain management. In doing so, the different professions are often in a competitive, tense, or dependent relationship resulting from a lack of precise definitions and concepts regarding their responsibilities in the wide field of pain management. Considering pain management as a whole, we can define numerous interfaces concerning competencies and tasks which may open up some new perspectives on concepts of interprofessional education (IPE). Internationally, there have been many attempts to establish concepts of interprofessional education, and it is considered a great challenge to improve continuing medical education. However, interdisciplinary subjects like pain management may benefit from it. Apart from enhancing specialized knowledge, interprofessional education aims to consider the different roles, skills, and responsibilities as well as interprofessional strategies of decision-making. In Germany, only a few efforts have been made with regard to interprofessional pain education. In the following paper, different challenges, tasks, and roles within the field of pain management are discussed in the sense of potential areas of collaboration in the context of interprofessional education. Against this background, the Regensburg model for interprofessional pain management education is described as one national program to enhance the effectiveness of pain management.

[Inpatient pain consultation service at a university hospital: a retrospective analysis of patient characteristics and the rate of the implementation of recommendations]. / Stationäre Schmerzkonsile einer universitären Schmerzambulanz : Eine retrospektive Analyse der Patientencharakteristika und der Umsetzungsrate der Empfehlungen.

BACKGROUND: The aim of this study was to conduct an audit of a university inpatient pain consultation service and to examine the quality and the implementation of the recommended therapeutic measures. Factors that influenced the implementation should be identified. PATIENTS AND METHODS: All inpatients treated by the consultation service in the years 2009 and 2010 were analyzed retrospectively. Demographic patient characteristics as well as quality parameters of the consultation service and pharmacological and non-pharmacological recommendations and their implementation were analyzed. RESULTS: In total 1,048 requests for the consultation service were processed of which 39.7% of the requests were for patients with acute pain, 33.8% with chronic and 19.9% with tumor-associated pain. Measures recommended most were medication, physiotherapy and psychological treatment. Recommended medications were actually prescribed in more than 80%, physiotherapy recommended in about 75% and psychological treatment recommended in 47% of the cases. Only a few influencing factors for the implementation of the recommended measures could be identified. CONCLUSION: Many different pain states are seen in an inpatient pain consultation service. The recommendations given are implemented in most cases especially concerning the medication.