[Emergency Care of Trauma Patients with the Bavarian "Rebel" Kit]. / Versorgung von Traumapatienten mit dem "REBEL"-Set.

BACKGROUND: Due to the increasing threat by terrorism and the resulting range of operations for the emergency medical service, the equipment as well as the rescue strategies are being adapted and expanded. An example is the "Recommended Action for Emergency Medical Services in Special Operations" (REBEL, Handlungsempfehlung für Rettungsdienst bei besonderen Einsatzlagen) of the highest Bavarian rescue service authority. In the following article, three cases are presented using new tools such as hemostyptics, thoracic patches and tourniquet from the REBEL kit in everyday operations. CASES: The first case deals with a seriously injured driver involved in a truck accident suffering from a scalping violation of the facial skeleton with consecutive critical bleeding (use of hemostyptics-coated dressings). The second case describes an accident with a reinforcing steel perforating a builder's chest. After removal of the perforating steel by first aiders, the two open thoracic wounds are supplied with thoracic closure patches. The third case deals with an amputation injury of the lower leg after a traffic accident (use of tourniquet). DISCUSSION: The most common causes of death besides bleeding that can be prevented in patients with severe injuries and multiple trauma are tension pneumothorax and airway obstruction. These diagnoses can be identified and treated properly using the ABCDE algorithm. In these cases, the new tools such as tourniquet, hemostyptics, chest decompression needles and thoracic closure patches can be used, which are increasingly held as an additional equipment in the ambulance vehicle. The application of these adjuvants requires a critical indication, competent knowledge and training of medical and non-medical emergency service personnel in theory and practice.

Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour.

BACKGROUND: Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties. OBJECTIVES: To systematically assess the effectiveness of remifentanil intravenous patient-controlled analgesia (PCA) for labour pain, along with any potential harms to the mother and the newborn. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 December 2015), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), handsearched congress abstracts (November 2015), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster-randomised trials comparing remifentanil (PCA) with another opioid (intravenous (IV)/intramuscular (IM)), or with another opioid (PCA), or with epidural analgesia, or with remifentanil (continuous IV), or with remifentanil (PCA, different regimen), or with inhalational analgesia, or with placebo/no treatment in all women in labour including high-risk groups with planned vaginal delivery. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted data, and appraised study quality.We contacted study authors for additional information other than incomplete outcome data. We performed random-effects meta-analysis.To reduce the risk of random error in meta-analysis we performed trial sequential analysis. We included total zero event trials and used a constant continuity correction of 0.01 (ccc 0.01) for meta-analysis. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS: Twenty RCTs with 3569 women were included. Of those, 10 trials (2983 participants) compared remifentanil (PCA) to an epidural, four trials (216 participants) to another opioid (IV/IM), three trials (215 participants) to another opioid (PCA), two trials (135 participants) to remifentanil (continuous IV), and one trial (20 participants) to remifentanil (PCA, different regimen). No trials were identified for the remaining comparisons.Methodological quality of studies was moderate to poor. We assessed risk of bias as high for blinding issues and incomplete outcome data in 65% and 45% of the included studies, respectively.There is evidence of effect that women in the remifentanil (PCA) group were more satisfied with pain relief than women in the other opioids (IV/IM) group (standardised mean difference (SMD) 2.11, 95% confidence interval (CI) 0.72 to 3.49, four trials, very low-quality evidence), and that women were less satisfied compared to women in the epidural group (SMD -0.22, 95% CI -0.40 to -0.04, seven trials, very low-quality evidence).There is evidence of effect that remifentanil (PCA) provided stronger pain relief at one hour than other opioids administered IV/IM (SMD -1.58, 95% CI -2.69 to -0.48, three trials, very low-quality evidence) or via PCA (SMD -0.51, 95% CI -1.01 to -0.00, three trials, very low-quality evidence). Pain intensity was higher in the remifentanil (PCA) group compared to the epidural group (SMD 0.57, 95% CI 0.31 to 0.84, six trials, low-quality evidence).Data were limited on safety aspects for both the women and the newborns. Only one study analysed maternal apnoea in a comparison of remifentanil (PCA) versus epidural and reported that half of the women in the remifentanil and none in the epidural group had an apnoea (very low-quality evidence). There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for maternal respiratory depression when compared to epidural analgesia (RR 0.91, 95% CI 0.51 to 1.62, ccc 0.01, three trials, low-quality evidence) and no reliable conclusion might be reached compared to remifentanil (continuous IV) (all study arms included zero events, two trials, low-quality evidence). In one trial of remifentanil (PCA) versus another opioid (IM) three out of 18 women in the remifentanil and none out of 18 in the control group had a respiratory depression (very low-quality evidence).There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for newborns with Apgar scores less than seven at five minutes compared to epidural analgesia (RR 1.26, 95% CI 0.62 to 2.57, ccc 0.01, five trials, low-quality evidence) and no reliable conclusion might be reached compared to another opioid (IV) and compared to remifentanil (PCA, different regimen) both with zero events in all study arms (one trial, very-low quality evidence). In one trial of remifentanil (PCA) versus another opioid (PCA) none out of nine newborns in the remifentanil and three out of eight in the opioid (PCA) group had Apgar scores less than seven (very-low quality evidence).There is evidence that remifentanil (PCA) was associated with a lower risk for the requirement of additional analgesia when compared to other opioids (IV/IM) (RR 0.57, 95% CI 0.40 to 0.81, three trials, moderate-quality evidence) and that it was associated with a higher risk compared to epidural analgesia (RR 9.27, 95% CI 3.73 to 23.03, ccc 0.01, six trials, moderate-quality evidence). There is no evidence of effect that remifentanil (PCA) reduced the requirement for additional analgesia compared to other opioids (PCA) (RR 0.76, 95% CI 0.45 to 1.28, three trials, low-quality evidence).There is evidence that there was no difference in the risk for caesarean delivery between remifentanil (PCA) and other opioids (IV/IM) (RR 0.63, 95% CI 0.30 to 1.32, ccc 0.01, four trials, low-quality evidence) and epidural analgesia (RR 1.0, 95% CI 0.82 to 1.22, ccc 0.01, nine trials, moderate-quality evidence), respectively. Pooled meta-analysis revealed an increased risk for caesarean section under remifentanil (PCA) compared to other opioids (PCA) (RR 2.78, 95% CI 0.99 to 7.82, two trials, very low-quality evidence). However, a wide range of clinically relevant and non-relevant treatment effects is compatible with this result. AUTHORS' CONCLUSIONS: Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.

Geburtshilfe: kombinierte Spinal-Epidural-Analgesie (CSE).

Due to intrathecal application, CSE combines rapid response with adequate analgesia with the possibility of providing unlimited neuraxial obstetrical pain relief via the indwelling epidural catheter. The superiority of CSE over EDA lies above all in its rapid action, excellent analgesia, lack of motor blockade after a single intrathecal opioid administration, lower rate of unilateral blockages and less need for subsequent epidural injections. The most common side effect is pruritus, which is harmless and usually does not require any therapeutic intervention. Even if no effect on rate of C-sections and APGAR values have been observed, the increased rate of fetal bradycardia after CSE must be kept in mind. A reduction of these fetal bradycardias and after intrathecal administration, prolongation of analgesia by means of appropriate drug combinations or additives should be the subject of future research.

[Indications and limitations for colloids in interventions and surgery]. / Indikationen und Limitationen für Kolloide bei Intervention und Operation.

BACKGROUND: Over the last few decades colloids have played an important part in the stabilisation of patients with acute need of intravascular volume replacement. After the 6S and the CHEST trials were published in 2012 and the subsequent recommendations of the European Medicines Agency (EMA) and the Food and Drug Administration (FDA) there has been some uncertainty about the current clinical relevance and routine use of colloids. OBJECTIVES: This article summarizes the current evidence and relevance of colloids in the perioperative environment and in the interventional setting on the basis of the recently published German S3-guidelines for volume therapy in adults. RESULTS: In situations of acute volume resuscitation colloids are still appropriate. Only colloids in balanced solutions should be used. Possible side effects, contraindications and the maximum daily dose have to be taken into consideration when administering colloids.

The effect of different lung-protective strategies in patients during cardiopulmonary bypass: a meta-analysis and semiquantitative review of randomized trials.

OBJECTIVES: A variety of lung-protective techniques, including continuous positive airway pressure and vital capacity maneuvers, have been suggested as beneficial when applied during cardiopulmonary bypass (CPB). To better define the efficacy of these techniques, a systematic review of different ventilation strategies during and after CPB was performed. DESIGN: A systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. SETTING: Hospitals. PARTICIPANTS: Eight hundred fourteen participants of 16 randomized controlled trials. INTERVENTIONS: Continuous positive airway pressure (CPAP), low-volume ventilation, or vital capacity maneuvers (VCMs) during CPB. MEASUREMENTS AND MAIN RESULTS: The methodologic validity of the included trials was scored according to the Oxford scale. Included trials had to report on at least 1 of the following parameters: oxygenation, oxygenation index, alveolar-arterial oxygen difference, or shunt fraction. The average quality of the included trials was as low as 2 on a scale from 1 to 5. The use of CPAP or VCM during CPB led to a significant increase in oxygenation parameters immediately after weaning from CPB, but this effect was not sustainable and did not improve patient outcome. CONCLUSIONS: This meta-analysis showed that the positive effects of the designated techniques are probably short-lived with a questionable impact on the long-term clinical outcome of the treated patients. Based on the available data, it might be impossible to advise an optimal or best-evidence strategy of lung preservation during CPB.