S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI).

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. / Kurzversion S2e-Leitlinie - "Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen".

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Euthanasia and physician-assisted suicide : Attitudes of physicians and nurses]. / Tötung auf Verlangen und assistierter Suizid : Einstellung von Ärzten und Pflegekräften.

BACKGROUND: The current debate about end-of-life decisions in Germany focuses on physician-assisted suicide (PAS). However, there is only limited information available on physicians' attitudes towards euthanasia or PAS, and no data on nurses' attitudes. OBJECTIVES: The aim is to explore attitudes of physicians and nurses with a special interest in palliative care and pain medicine using a case-related questionnaire. METHODS: An anonymous questionnaire, consisting of eight questions, was distributed to all participants of a palliative care congress and a pain symposium. The questions focused on two scenarios: (1) a patient with an incurable fatal illness, (2) a patient with an incurable but nonfatal illness. The question was: Should euthanasia or physician-assisted suicide (PAS) be allowed. In addition, the participants were asked what they wanted for themselves if they were the patient concerned. RESULTS: A total of 317 questionnaires were analyzed; the return rate was 70 %. The general support for euthanasia and PAS was high: 40.5 % supported euthanasia in case of a fatal illness ("definitely…", "probably should be allowed"), 53.5 % supported PAS. The support decreased in case of a nonfatal illness; however, it increased when the participants were asked about their attitudes if they were the patient concerned. Nurses were more open towards euthanasia and PAS. In physicians the rejection of PAS was directly related to a higher level of qualification in the field of palliative care. CONCLUSION: The fact that nurses had a more positive attitude towards euthanasia and PAS and that all respondents accepted life-ending acts for themselves more than for their patients hints to still existing severe deficits in Germany.

[An algorithm for postoperative pain management in visceral and thoracic surgery: an observational study]. / Algorithmus zur postoperativen Schmerztherapie in der Viszeral- und Thoraxchirurgie: Eine Verlaufuntersuchung.

INTRODUCTION: We report the results of an observational study of pain intensity before and after implementation of an algorithm for postoperative pain management. The algorithm included multiple factors for treatment. METHODS: Data of 130 consecutive patients with defined surgical procedures were extracted from charts before and after implementation of the algorithm. Our patients documented pain intensity at rest and on movement on a numerival rating scale (NRS) from 0 (= no pain) to 10 (=  worst pain). A successful pain management was definded as maximum pain intensity at rest ≤ 3 and on movement ≤ 5 on the NRS. For statistical analysis we used the Wilcoxon and the chi squared test. RESULTS: The frequency of a successful pain management increased from 49 % (individual pain management) to 85 % (algorithm) at rest 8 (p < 0.001), on movement the rates were 42 % and 86 %, respectively (p < 0.001). In the total group, we found a reduction of maximum pain intensity at rest (mean ±â€Šsd) from 4.05  ±â€Š 2.54 to 2.18 ±â€Š1.82 (p < 0.001) and with movement from 6.04 ±â€Š2.51 to 3.5 ±â€Š2.08 (p < 0.001). CONCLUSION: Implementing an algorithm for postoperative pain management resulted in a clinically relevant reduction of postoperative pain. Our findings reflect the result of a complex change in pain management, and therefore cannot be attributed to any single factors involved.

Meta-analysis of dropout rates in randomized controlled clinical trials: opioid analgesia for osteoarthritis pain.

BACKGROUND: The interpretation of opioid studies in patients with chronic pain due to osteoarthritis is limited by a high dropout rate. Therefore, the implication of dropouts on the recommendation of opioids in chronic osteoarthritis pain was analyzed. DATA SOURCES: The databases of Medline, Embase, the Cochrane Library, and the Internet from 1990-2009 were searched. STUDY SELECTION: Two independent authors included randomized controlled clinical trials investigating the effects of chronic opioid treatment for the management of osteoarthritis pain. In order to calculate the odds ratio, only placebo-controlled trials were included. DATA EXTRACTION: The primary outcome parameter was the dropout rate. Secondarily, the effect size was calculated. Data extraction was conducted by two independent authors. RESULTS: A total of 19 studies reporting results of 3,871 treatment and 2,080 placebo outcomes were retrieved. Compared to placebo, opioid treatment was associated with a significantly increased total dropout rate (OR = 1.3, 95%CI 1.2-1.4). Discontinuation of treatment was related to adverse events (OR = 4.0, 95%CI 3.4-4.6). Lack of analgesia was associated with a significantly reduced dropout rate in opioid groups (OR = 0.4, 95%CI 0.3-0.5). Analgesic effects were significantly better in opioid-treated patients (p = 0.01). CONCLUSION: In spite of analgesic effects, many osteoarthritis patients prefer to stop chronic opioid use, because of adverse events. Therefore, opioids are not generally recommended in osteoarthritis.

Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis.

Intrathecal morphine is often used for postoperative analgesia after surgery. We performed a meta-analysis to obtain more detailed information on the frequency of side-effects in patients receiving intrathecal morphine in combination with spinal anaesthesia compared with placebo treated patients. We clustered the analysis to patients receiving placebo, less than morphine 0.3 mg (M < 0.3), or equal to or more than morphine 0.3 mg (M > or = 0.3) and calculated the risk ratios of morphine vs placebo. Twenty-eight studies investigating 46 morphine groups vs placebo were included. A total of 790 patients with intrathecal morphine and 524 patients who received placebo were analysed. Compared with placebo the lower dose of morphine resulted in an increase of nausea (RR 1.4, 95% CI 1.1-1.7), vomiting (RR 3.1, 95% CI 1.5-6.4) and pruritus (RR 1.8, 95% CI 1.4-2.2). The higher dose resulted in an increased risk ratio for pruritus (RR 5.0, 95% CI 2.9-8.6), but not nausea (RR 1.2, 95% CI 0.9-1.6) or vomiting (RR 1.3, 95% CI 0.9-1.9). Overall, intrathecal morphine did not increase respiratory depression. However, the higher dose of intrathecal morphine was associated with more episodes of respiratory depression (7/80) compared with the lower dose (2/247). Intrathecal morphine is associated with a mild increase in side-effects. With a dose < 0.3 mg we found there were no more episodes of respiratory depression than in placebo patients who received systemic opioid analgesia.

The effective duration of analgesia after intrathecal morphine in patients without additional opioid analgesia: a randomized double-blind multicentre study on orthopaedic patients.

BACKGROUND AND OBJECTIVE: To know whether the application of patient-controlled analgesia devices could be avoided if intrathecal morphine is given in combination with spinal anaesthesia. METHODS: In a randomized, double-blind multicentre study, 188 orthopaedic patients were randomized to receive intrathecally placebo, 0.1 mg morphine or 0.2 mg morphine in addition to 15 mg bupivacaine. The primary outcome parameter was the number of patients without any additional request for opioid during a period of 72 h after surgery. RESULTS: Patients with 0.1 or 0.2 mg morphine showed a significant reduction in opioid requests compared with placebo during 72 h after surgery (P = 0.0001). At 24 h after surgery, the rate of patients who required additional opioid analgesia was 71% in the placebo group, 51% in the 0.1 mg morphine group and 31% of the patients in the 0.2 mg morphine group. After 0.2 mg morphine, systemic opioid requirements at 24 h were significantly lower than those in patients with 0.1 mg morphine (P < 0.05). Intrathecal morphine was not associated with an increased frequency of respiratory depression. Forty per cent of patients with intrathecal morphine did not ask for systemic opioids. CONCLUSION: Intrathecal morphine in a dose of 0.1 and 0.2 mg provides effective analgesia for up to 48 h without any need for systemic opioids at all in many patients.

[Ventilation hazard caused by a soft ventilation bag]. / Materialbedingte Gefährdung der Beatmung durch weichen Beatmungsbeutel.

The introduction of a new ventilation bag was associated with the occurrence of an unexpected ventilation problem. The analysis revealed a technical problem related to the high plasticity of the new bag allowing incomplete obstruction due to torsion of the anesthesia bag.

[Intrathecal morphine in orthopaedic surgery patients. Optimised dose in patients receiving dipyrone]. / Intrathekal verabreichtes Morphin bei orthopädischen Eingriffen. Optimierte Dosis bei Koanalgesie mit Metamizol.

INTRODUCTION: The influence of different postoperative doses of intrathecal morphine on the time of first opioid request by orthopaedic patients was investigated. The first choice analgesic was dipyrone and a maximum dose of 6 mg/day was allowed. METHODS: A prospective, double-blind, placebo-controlled, clinical trial was conducted with 15 patients in each group receiving intrathecally either a placebo, 0.05 mg morphine, 0.1 mg morphine or 0.2 mg morphine in combination with a spinal anaesthesia with isobaric bupivacaine. RESULTS: The number of patients without opioid requirement during the first 24 h after surgery were 3, 8, 14 and 14 in the placebo group and after 0.05 mg (p=0.128), 0.1 mg (p=0.0001) and 0.2 mg (p=0.0001) intrathecal morphine, respectively. The average time until first opioid requirement increased in a dose-dependent manner from 10.3 h to 23.9 h (p<0.0001). CONCLUSION: In orthopaedic patients with dipyrone as the primary analgesic, the addition of 0.1 mg or 0.2 mg morphine to spinal anaesthesia provided a simple long-lasting postoperative analgesia and the use of additional opioids could be avoided during the 24h postoperative period.

[Complex regional pain syndrome I and II. What effects the outcome?]. / Komplexe regionale Schmerzsyndrome CRPS I und II. Was beeinflusst den Langzeitverlauf?

INTRODUCTION: The results of clinical studies have raised doubts on the effectiveness of regional sympathetic blocks with guanethidine (IVRSB) in patients suffering from complex regional pain syndrome (CRPS). We conducted a retrospective analysis of long-term results in our patients and searched for possible factors predicting long-term outcome after IVRSB: METHODS: After approval by our ethics commission and written informed consent, 42/44 patients were included. We documented diagnosis, history, therapy and long-term result from charts. Long-term results were also obtained from a questionnaire administered to the patients. These were defined as very good (reduction of pain > or =75%), good (pain reduction <75% and > or =50%), moderate (pain reduction <50% and > or =25%) or poor (pain reduction <25%). The association of a moderate or poor outcome with the factors age, gender, duration of time until therapy, pain intensity before therapy, dose of applied guanethidine and duration of therapy was calculated by odds ratio. Confidence intervals for the odds ratios were determined by Woolfs approximation. RESULTS: After a mean duration of 18 months, the outcome was classified as very good in 14, good in 13, moderate in 5 and poor in 10 patients. An increased rate of moderate or poor outcome was associated with age<60 years (OR=4.00, CI 1.04-15.26), male gender (OR=2.93, CI 0.71-12.11) and duration of therapy>2 weeks (OR=3.27, CI 0.86-12.36). The factors duration of time until therapy, initial pain intensity and total dose of guanethidine were not associated with increased rates of moderate or poor outcome. CONCLUSION: We only seldom observed a complete functional restoration after CRPS. Male patients <60 years showed an increased risk of developing chronic pain. It remains unclear whether the risk of chronic pain reflects different responses to therapy or differences in the natural course of the disease in our patients. A meta-analysis of randomised trials of IVRSB in CRPS failed to prove the effectiveness of this intervention. If other investigations confirm our impression, future studies of CRPS-treatments should be planned and analysed with regard to the possible influence of the natural course and different risks of chronic pain among patients with CRPS.

[Can the addition of clonidine improve the analgesic efficacy of low dose intrathecal morphine? A randomised double-blind trial]. / Verbessert der Zusatz von Clonidin zur Spinalanästhesie die analgetische Wirkung niedrig dosierten intrathekalen Morphins? Eine randomisierte doppelblinde Studie.

OBJECTIVE: To evaluate the influence of intrathecal clonidine on spinal morphine analgesia and adverse effects after major orthopaedic surgery. METHODS: The study was approved by the local Ethics Committee.After written informed consent, 45 ASA I-III patients scheduled for hip or knee replacement were included. Patients were randomly allocated to receive either placebo, 0.1 mg morphine or 0.1 mg morphine+50 microg clonidine in addition to 15 mg bupivacaine intrathecally. The primary outcome parameter was the time to first opioid request. Statistical differences were calculated with U-test or Fisher's exact test. RESULTS: Clonidine did not result in a significant improvement of postoperative analgesia. The mean time until first opioid request was for placebo 10.3+/-7.9 h, for 0.1 mg morphine 23.0+/-3.9 h and for 0.1 mg morphine+ 50 microg clonidine 21+/-6.9 h, respectively. Clonidine significantly increased the rate of adverse effects. CONCLUSION: Our trial did not confirm an improved analgesia with the combination of intrathecal morphine and clonidine. Due to increased adverse effects the combination of intrathecal clonidine and morphine does not seem to be a reasonable alternative in the management of postoperative pain after orthopaedic surgery.

[Prophylaxis of phantom pain: is regional analgesia ineffective?]. / Prophylaxe von Phantomschmerzen: Sind regionale Analgesieverfahren unwirksam?

AIM: A recently published randomized study failed to show a significant reduction of phantom limb pain after perioperative epidural analgesia EDA [9]. Since these findings were not supported by previous studies,we conducted an analysis of factors contributing to the results of phantom limb pain prophylaxis. We calculated the efficacy of perioperative EDA as "Number Needed to Treat" (NNT). METHODS: Included studies were retrieved by a medline-search from 1966 to 1999 and published articles on phantom limb pain prophylaxis. First,we analyzed the influence of patient data, type of intervention and study design on the results. Then,we stratified studies in comparable groups and outcome measures. The efficacy of perioperative EDA in phantom limb pain prophylaxis was calculated using NNT's. The outcome criterion in this analysis was "free of phantom limb pain < or = 3 on an analogue scale from 0 ( no pain) to 10 (worst pain) 12 months after amputation". RESULTS: Variations in preoperative pain, start and duration of regional analgesia and the definition of phantom limb pain were associated with different results. After stratifying the results by the above mentioned definition of phantom pain intensity, only time and duration of regional analgesia showed effects on the study results. Pre-, intra- and postoperative EDA was associated with a significant reduction of phantom limb pain 12 months after amputation, NNT = 5,8 (95%-CI 3,2-28,6). However, a reduction of phantom limb pain by postoperative EDA alone could not be confirmed on the basis of the analysed data. CONCLUSIONS: Perioperative EDA has been shown to be an effective prophylaxis of phantom limb pain. The most important differences between studies were the definition of phantom limb pain by intensity ratings. Thus, perioperative EDA does not completely abolish phantom limb pain, but increases the number of patients with a mild form of phantom pain.

The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients.

OBJECTIVE: To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients. DESIGN: Three strategies were used to estimate the mortality attributable to bleeding in two multicentre databases. The first method matched patients who bled with those who did not (matched cohort), using duration of ICU stay prior to the bleed, each of six domains of the Multiple Organ Dysfunction Score (MODS) measured 3 days prior to the bleed, APACHE II score, age, admitting diagnosis, and duration of mechanical ventilation. The second approach employed Cox proportional hazards regression to match bleeding and non-bleeding patients (model-based matched cohort). The third method, instead of matching, derived estimates based on regression modelling using the entire population (regression method). Three parallel analyses were conducted for the length of ICU stay attributable to clinically important bleeding. SETTING: Sixteen Canadian university-affiliated ICUs. PATIENTS: A total of 1666 critically ill patients receiving mechanical ventilation for at least 48 hours. MEASUREMENTS: We prospectively collected data on patient demographics, APACHE II score, admitting diagnosis, daily MODS, clinically important bleeding, length of ICU stay, and mortality. Independent adjudicators determined the occurrence of clinically important gastrointestinal bleeding, defined as overt bleeding in association with haemodynamic compromise or blood transfusion. RESULTS: Of 1666 patients, 59 developed clinically important gastrointestinal bleeding. The mean APACHE II score was 22.9 +/- 8.6 among bleeding patients and 23.3 +/- 7.7 among non-bleeding patients. The risk of death was increased in patients with bleeding using all three analytic approaches (matched cohort method: relative risk [RR]= 2.9, 95% confidence interval (CI)= 1.6-5.5; model-based matched cohort method: RR = 1.8, 95% CI = 1.1-2.9; and the regression method: RR = 4.1, 95% CI = 2.6-6.5). However, this was not significant for the adjusted regression method (RR = 1.0, 95% CI = 0.6-1.7). The median length of ICU stay attributable to clinically important bleeding for these three methods, respectively, was 3.8 days (95% CI = -0.01 to 7.6 days), 6.7 days (95% CI = 2.7-10.7 days), and 7.9 days (95% CI = 1.4-14.4 days). CONCLUSIONS: Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.

[Prevention of "post-sevoflurane delirium" with midazolam]. / Prophylaxe des "Postsevoflurandelirs" mit Midazolam.

In a randomized double-blind placebo-controlled trial in children 2-7 years of age, we investigated the effect of a single prophylactic midazolam bolus (0.1 mg/kg b.w.) prior to the termination of anaesthesia, on the incidence and severity of agitation occurring after sevoflurane administration. Compared to the placebo group, midazolam prophylaxis significantly decreased the incidence of postanaesthetic delirium. However, the incidence of severe agitation requiring treatment was not different between the groups (placebo: n = 6; midazolam: n = 4). The mean severity of agitation was significantly lower in patients with midazolam prophylaxis. When midazolam was administered for the treatment of severe agitation it reduced the severity but did not abolish agitation. All patients were discharged from the recovery room after the 2 h observation period. From our study we conclude that a small prophylactic midazolam bolus is able to reduce the incidence and severity of agitation after sevoflurane anesthesia in some patients but is insufficiently effective in patients with severe agitation. Thus, the prophylactic administration of midazolam extenuates but does not solve the problem of post-sevoflurane agitation.

Clonidine prevents sevoflurane-induced agitation in children.

UNLABELLED: In a double-blinded trial, 40 male children (age 2-7 yr) undergoing circumcision were randomly assigned to receive clonidine 2 microg/kg IV or placebo after anesthetic induction. For induction and maintenance of anesthesia, we used sevoflurane as the sole anesthetic. For pain treatment, a penile block was performed before surgery. After surgery the incidence and severity of agitation was measured during an observation period of 2 h. Severe agitation was treated with midazolam. In 16 placebo and 2 clonidine-treated patients agitation was observed (P < 0.001). In 6 patients of the Placebo group, agitation was graded as severe, whereas none of the patients in the Clonidine group developed severe agitation (P = 0.02). During the postoperative period heart rate and blood pressure were significantly decreased in clonidine treated patients (P < 0.05). We conclude that clonidine effectively prevents agitation after sevoflurane anesthesia. IMPLICATIONS: The recovery from sevoflurane anesthesia may be complicated by the presence of agitation in pediatric patients. Clonidine 2 microg/kg IV after anesthetic induction effectively reduces the incidence of agitation without resulting in clinically relevant bradycardia and hypotension.

Role of acid suppressants in intensive care medicine.

Bleeding from stress-induced mucosal lesions continues to be a potential problem in critically ill patients, although its incidence has decreased dramatically over the past decade. Patients considered to be at risk are those with respiratory failure, coagulopathy, severe burns or tetraplegia. The most important cause of stress ulcer bleeding is tissue hypoxia. Provided that appropriate dosage regimens are administered, all agents approved for stress ulcer prophylaxis may reduce the incidence of overt as well as clinically important bleeding. However, the efficacy of stress ulcer prophylaxis does not correlate with the efficacy of gastric acid inhibition. Although numerous studies have demonstrated that an alkaline gastric juice is associated with gastric Gram-negative bacterial overgrowth, controversy remains over whether the pharmacological suppression of gastric acid in critically ill patients facilitates nosocomial pneumonia. The reasons for these divergent results are discussed, as is a possible association between gastric acid suppression and other systemic infections. Finally, several cost-effectiveness analyses performed over recent years have demonstrated that, in properly selected critically ill patients, stress ulcer prophylaxis is cost-effective.

[Myocardial infarction during pregnancy]. / Myokardinfarkte in der Schwangerschaft.

Up to now 136 cases of myocardial infarction during pregnancy have been reported, and angiography revealed normal findings in 47%. In these cases coronary spasms have been discussed as the major mechanism of the disease. In isolated cases coronary artery dissection may also present with a normal coronary angiography. The case of a 31-year-old pregnant women who developed myocardial infarction during a caesarean section under spinal anaesthesia gives rise to the assumption that an early stage of coronary artery disease may be the third cause that has to be considered. Probably as a consequence of phases of tachycardia and hypertension during the course of anaesthesia, the patient developed a myocardial infarction that she survived without sequelae. While coronary angiography showed normal coronary vessels, an intravascular ultrasound study (IVUS) demonstrated an atheroma in the left main coronary artery with a ruptured fibrous cap. Laboratory screening for risk factors of coronary artery disease (CAD) showed hypercholesterinemia, increased factor VII activity and hyperfibrinogenemia. Platelet aggregation was not inhibited by acetylsalicylic acid. It was pointed out recently that even in asymptomatic patients, plaques may be present in coronary vessels indicating an early stage of CAD that cannot be diagnosed by angiography. Plaque rupture is often triggered by hypertension and may lead to myocardial infarction, instable angina pectoris, or sudden ischemic death. As IVUS is a new diagnostic tool that allows diagnoses of even early stages of CAD we believe that myocardial infarction during pregnancy is more often caused by plaque rupture than may be expected according to the current literature.