[Peripartum hemorrhage, diagnostics and treatment : Update of the S2k guidelines AWMF 015/063 from August 2022]. / Peripartale Blutungen, Diagnostik und Therapie : Update der S2k-Leitlinie AWMF 015/063 vom August 2022.

The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.

[Prioritization of intensive medical treatment places - Concept proposal]. / Priorisierung intensivmedizinischer Behandlungsplätze ­ Konzeptvorschlag.

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.

[Perioperative enhanced recovery after surgery program for Ivor Lewis esophagectomy : First experiences of a high-volume center]. / Perioperatives "Enhanced-recovery-after-surgery"-Programm der Ivor-Lewis-Ösophagektomie : Erste Erfahrungen eines High-volume-Zentrums.

BACKGROUND AND OBJECTIVE: Transthoracic esophagectomy is generally accepted as the standard of surgical care for patients with esophageal cancer. Despite improvements in the perioperative management this surgical procedure is associated with a clinically relevant morbidity. Fast-track protocols (synonym: enhanced recovery after surgery, ERAS) are conceived to perioperatively maintain the physiological homoeostasis and thereby to accelerate postoperative rehabilitation and reduce morbidity. In this prospective observational study the initial experiences of a high-volume center with the implementation of an ERAS protocol after transthoracic esophagectomy were analyzed. MATERIAL AND METHODS: A total of 26 patients with esophageal cancer and a low index of comorbidities prior to hybrid Ivor Lewis esophagectomy were included in this study. According to an ERAS protocol all patients underwent a standardized perioperative treatment pathway aiming to discharge the patients from the inpatient treatment on postoperative day 10. The primary outcome parameter was the rate of major complications (Clavien-Dindo IIIb/IV), which was compared to a cohort of 52 non-ERAS patients. RESULTS AND CONCLUSION: The ERAS programs with the various core elements can be implemented in patients scheduled for transthoracic esophagectomy, although the organizational and personnel expenditure of this fast-track protocol is high. The length of hospital stay appears to be reduced without compromising patient safety. The limiting variable of the ERAS protocol remains the early and adequate enteral feeding load of the gastric conduit before discharge on postoperative day 10.

[Acute treatment of pregnant women after severe trauma-a retrospective multicenter analysis]. / Akutbehandlung schwangerer Patientinnen nach schwerem Trauma ­ eine retrospektive Multicenteranalyse.

BACKGROUND: For the medical team, the management of pregnant trauma patients is a particular challenge. The aim of this study is to compile this data and to determine differences between pregnant and not pregnant trauma patients. MATERIALS AND METHODS: We carried out a retrospective data analysis from the TraumaRegister DGU® with a comparison of 102 pregnant and 3135 not pregnant women of child-bearing age (16-45 years) from 2016-2018 who were treated in a trauma center. All patients were delivered to the resuscitation room and received intensive care treatment. RESULTS: In Germany, Austria and Switzerland 3.2% of all trauma patients (102 women) were pregnant. Women with an average age of 29 years suffered most often trauma as a result of a road traffic accident. Major trauma (Injury Severity Score [ISS] ≥16 points) was seen in 24.5% of the pregnant women and 37.4% of the nonpregnant women. A computer tomography (whole body computer tomography) was carried out in 32.7% of all pregnant women but in 79.8% of the nonpregnant women. As a result of the trauma, 2.9% of the pregnant and 3.5% of the not pregnant women died. The standardised mortality rate (SMR) was 0.42 in pregnant women and 0.63 in nonpregnant women. CONCLUSION: For the first time there is data regarding incidence, trauma mechanism, prehospital and in-hospital care as well as intensive care of pregnant trauma patients in Germany, Austria and Switzerland. Further research regarding foetal outcome and trauma-related injuries in pregnant women is needed to develop an adjusted management for these patients ready to implement in trauma centres. Gynaecologists and obstetricians should be implemented in the trauma room team when needed.

[Development of a new module for the TraumaRegister DGU® : Better collation of the sequelae of severe injuries during pregnancy]. / Entwicklung eines neuen Moduls für das TraumaRegister DGU® : Folgen schwerer Verletzungen während der Schwangerschaft besser erfassen.

BACKGROUND: Life-threatening injuries during pregnancy are a rare occurrence. The TraumaRegister DGU® (TR-DGU) has been recording whether seriously injured women were pregnant since 2016. This information is not sufficient to enable a differentiated assessment of the quality of care because parameters, such as gestational age, state of pregnancy at discharge and survival of the child are missing. The TraumaRegister working group of the committee on emergency medicine, intensive care and severe trauma management (section NIS) of the German Trauma Society (DGU) therefore came to the conclusion that the fetal outcome or the intactness of the pregnancy after acute treatment is an important measure of the quality of care of pregnant women. They commissioned a task force to work out a suitable data set for a better analysis of such cases. This article presents the so-called fetus module in detail. METHODS: The data set was developed in an interdisciplinary process together with accredited experts from the German Society for Gynecology and Obstetrics (DGGG), the German Society for Perinatal Medicine (DGPM) and the Society for Neonatology and Pediatric Intensive Care Medicine (GNPI). RESULTS: The fetus module comprises 20 parameters describing the pregnancy, the condition of the mother and child on admission and discharge. CONCLUSION: The fetus module will provide important data to make the process and outcome quality of care of severely injured pregnant women measurable and to develop prognostic instruments with which predictions about high-risk constellations for the outcome of mother and child can be made.

[Selection of the optimal anesthesia regimen for cesarean section]. / Wahl des Anästhesieverfahrens zur Sectio caesarea.

Approximately one third of all children in Germany are delivered by cesarean section. Depending on the individual patient's condition and the situation, the anesthesiologist has to choose between a general or a regional anesthesia regimen. The decisive factor for the selection is the obstetric urgency (decision-delivery time) after ascertainment of the indications. Furthermore, the need for postoperative analgesia varies depending on the chosen anesthesia regimen.

[Hot topics in obstetric anesthesia]. / "Hot topics" aus der geburtshilflichen Anästhesie.

In 2019 the annual conference of the scientific working group on obstetric anesthesiology of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) took place in the usual manner. Emergency situations, such as the challenge of a preclinical birth or the recognition and treatment of an amniotic fluid embolism were discussed. In addition, topics on the correct treatment of a female patient with a known addictive disorder were of great interest as well as the discussion on the question when a transfusion should be performed in postpartum anemia and which risks accompany the increasing prevalence of obesity, especially during pregnancy. A further hot topic was the deliberation on the prevalence and differential diagnostic clarification of neurological complications after epidural anesthesia. In connection with the topic of birth, exciting and practice relevant topics for all anesthetists confronted with this field were presented and discussed. The essential aspects are summarized in this article.

Intra-patient potassium variability after hypothermic cardiac arrest: a multicentre, prospective study.

BACKGROUND: To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests. METHODS: Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL). RESULTS: Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were - 1.6 to + 1.7 mmol/L; - 1.18 to + 2.7 mmol/L and - 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium. CONCLUSIONS: We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03096561.

On-the-Scene Hyaluronan and Syndecan-1 Serum Concentrations and Outcome after Cardiac Arrest and Resuscitation.

BACKGROUND: It is not predictable which patients will develop a severe inflammatory response after successful cardiopulmonary resuscitation (CPR), also known as "postcardiac arrest syndrome." This pathology affects only a subgroup of cardiac arrest victims. Whole body ischemia/reperfusion and prolonged shock states after return of spontaneous circulation (ROSC) may both contribute to this devastating condition. The vascular endothelium with its glycocalyx is especially susceptible to initial ischemic damage and may play a detrimental role in the initiation of postischemic inflammatory reactions. It is not known to date if an immediate early damage to the endothelial glycocalyx, detected by on-the-scene blood sampling and measurement of soluble components (hyaluronan and syndecan-1), precedes and predicts multiple organ failure (MOF) and survival after ROSC. METHODS: 15 patients after prehospital resuscitation were included in the study. Serum samples were collected on the scene immediately after ROSC and after 6 h, 12 h, 24 h, and 48 h. Hyaluronan and syndecan-1 were measured by ELISA. We associated the development of multiple organ failure and 30-day survival rates with these serum markers of early glycocalyx damage. RESULTS: Immediate serum hyaluronan concentrations show significant differences depending on 30-day survival. Further, the hyaluronan level is significantly higher in patients developing MOF during the initial and intermediate resuscitation period. Also, the syndecan-1 levels are significantly different according to MOF occurrence. CONCLUSION: Serum markers of glycocalyx shedding taken immediately on the scene after ROSC can predict the occurrence of multiple organ failure and adverse clinical outcome in patients after cardiac arrest.

Acupuncture reduces the time from extubation to 'ready for discharge' from the post anaesthesia care unit: results from the randomised controlled AcuARP trial.

Acupuncture may improve peri-operative care as it reduces post-operative symptoms, such as pain, nausea and vomiting, or sedation. This patient-assessor blinded, randomised trial in 75 women undergoing gynaecologic laparoscopy evaluated the effects of acupuncture combined with a standardised anaesthetic regimen (ACU) on post-anaesthetic recovery, when compared to acupressure (APU) or standard anaesthesia alone (CON). Main outcome measure was the time from extubation to 'ready for discharge' from recovery as assessed by validated questionnaires. The main outcome differed significantly between groups (p = 0.013). Median time to ready for discharge in the ACU group (30 (IQR: 24-41) min) was 16 minutes (35%) shorter than in the CON group (46 (36-64) min; p = 0.015) and tended to be shorter than in the APU group (43 (31-58) min; p = 0.08). Compared to CON (p = 0.029), median time to extubation was approximately 7 minutes shorter in both, the ACU and the APU group. No acupuncture or acupressure-related side-effects could be observed. A difference in time to recovery of 16 minutes compared to standard alone can be considered clinically relevant. Thus, results of this study encourage the application of acupuncture in gynaecological laparoscopy as it improves post-anaesthetic recovery.

[Cancer patients in operative intensive care medicine]. / Krebspatienten in der operativen Intensivmedizin.

Cancer is one of the leading causes of death worldwide. New targeted and individualized therapies and drugs provide a survival benefit for an increasing number of patients, but can also cause severe side effects. An increasing number of oncology patients are admitted to intensive care units (ICU) because of cancer-related complications or treatment-associated side effects. Postoperative care, respiratory distress and sepsis are the leading causes for admission. Tumor mass syndromes and tumor lysis may require urgent treatment. Traditional anticancer chemotherapy is associated with infections and immunosuppression. Newer agents are generally well-tolerated and side effects are mild or moderate, but overwhelming inflammation and autoimmunity can also occur. Cellular treatment, such as with chimeric antigen receptor modified T­cells, monoclonal and bispecific antibodies targeting immune effectors and tumor cells are associated with cytokine release syndrome (CRS) with hypotension, skin reactions and fever. It is related to excessively high levels of inflammatory cytokines. Immune checkpoint inhibitors can lead to immune-related adverse events (IRAEs), such as colitis and endocrine disorders. Noninfectious respiratory complications, such as pneumonitis can also occur. Recent studies revealed that short-term and medium-term survival of cancer patients is better than previously expected. In this review article we summarize diagnostic and treatment strategies for common life-threatening complications and emergencies requiring ICU admission. Furthermore, strategies for rational admission policies are presented.

[Chest decompression in emergency medicine and intensive care]. / Die Thoraxdekompression in der Notfall- und Intensivmedizin.

Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.

[Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]. / Perioperatives Management der transthorakalen Ösophagektomie : Grundlagen der interdisziplinären Patientenversorgung und neue Konzepte zur beschleunigten postoperativen Erholung.

Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.

[Anesthesia in obstetrics: Tried and trusted methods, current standards and new challenges]. / Anästhesie in der Geburtshilfe: Altbewährtes, gegenwärtige Standards und neue Herausforderungen.

Obstetric analgesia and anesthesia have some specific aspects, which in particular are directly related to pathophysiological alterations during pregnancy and also to the circumstance that two or even more individuals are always affected by complications or therapeutic measures. This review article deals with some evergreens and hot topics of obstetric anesthesia and essential new knowledge on these aspects is described. The article summarizes the talks given at the 16th symposium on obstetric anesthesia organized by the Scientific Committee for Regional Anaesthesia and Obstetric Anaesthesia within the German Society of Anaesthesiology. The topics are in particular, special features and pitfalls of informed consent in the delivery room, challenges in education and training in obstetric anesthesia, expedient inclusion of simulation-assisted training and further education on risk minimization, knowledge and recommendations on fasting for the delivery room and cesarean sections, monitoring in obstetric anesthesia by neuraxial and alternative procedures, the possibilities and limitations of using ultrasound for lumbal epidural catheter positioning in the delivery room, recommended approaches in preparing peridural catheters for cesarean section, basic principles of cardiotocography, postoperative analgesia after cesarean section, the practice of early bonding in the delivery room during cesarean section births and the management of postpartum hemorrhage.

[Anesthesia and pain management during pregnancy]. / Anästhesie und Schmerztherapie während der Schwangerschaft.

During the perioperative and postoperative care of pregnant women it is prudent to pay close attention to the changed physiology of these patients. The main principles of care are the preservation of maternal and fetal homeostasis as well as avoidance of any substances with toxic effects on the fetus. In order to provide pregnant patients with good quality care, all relevant disciplines should be involved as early as possible. Modern anesthetic drugs can be used as they seem to be without teratogenic effects. Adequate perioperative surveillance and assessment of the fetus is also important.The mainstay of pain management during pregnancy is the World Health Organization (WHO) pain ladder. It is of the utmost importance to use only substances without teratogenic or fetotoxic properties. Considering non-opioid drugs, the use of paracetamol is a viable option, whereas non-steroidal anti-inflammatory drugs (NSAID) should only be used with rigorous restrictions. Tramadol is a first-line drug when using opioids with low potency, whereas morphine can be used as an opioid with a higher potency after careful consideration of the risk-benefit ratio. If possible anticonvulsives should not be used as an adjunct in pain management during pregnancy. The use of thoroughly investigated antidepressants seems to be a better alternative. Apart from drug therapy it is important to use all available conservative pain treatment options.

[Tuberculous encephalitis, Landouzy sepsis and Pott's disease: complications after surgery for spinal stenosis]. / Tuberkulöse Enzephalitis, Landouzy-Sepsis und Pott-Krankheit : Komplikationen nach operativer Versorgung einer Spinalkanalstenose.

Tuberculosis is an infectious disease with a decreasing incidence in Germany. In particular, the occurrence of reinfections and possible complications associated with this disease, such as tuberculous meningitis/encephalitis and Landouzy sepsis are rare in industrial countries. In this article the intensive care treatment of a patient who initially underwent surgery for spinal stenosis is reported. Due to recurrent appearance of neurological symptoms with increasing severity and abscess formation in the spine, further surgery was performed. Additionally, the patient developed sepsis and meningitis. At this time an infection with Mycobacterium tuberculosis could be detected in both cerebrospinal fluid and abscess material of the spine suggesting a Landouzy sepsis, tuberculous meningitis/encephalitis and the suspicion of an underlying Pott's disease.

Inosine, not adenosine, initiates endothelial glycocalyx degradation in cardiac ischemia and hypoxia.

Ischemia/reperfusion and hypoxia/reoxygenation of the heart both induce shedding of the coronary endothelial glycocalyx. The processes leading from an oxygen deficit to shedding are unknown. An involvement of resident perivascular cardiac mast cells has been proposed. We hypothesized that either adenosine or inosine or both, generated by nucleotide catabolism, attain the concentrations in the interstitial space sufficient to stimulate A3 receptors of mast cells during both myocardial ischemia/reperfusion and hypoxia/reoxygenation. Isolated hearts of guinea pigs were subjected to either normoxic perfusion (hemoglobin-free Krebs-Henseleit buffer equilibrated with 95% oxygen), 20 minutes hypoxic perfusion (buffer equilibrated with 21% oxygen) followed by 20 minutes reoxygenation, or 20 minutes stopped-flow ischemia followed by 20 minutes normoxic reperfusion (n = 7 each). Coronary venous effluent was collected separately from so-called transudate, a mixture of interstitial fluid and lymphatic fluid appearing on the epicardial surface. Adenosine and inosine were determined in both fluid compartments using high-performance liquid chromatography. Damage to the glycocalyx was evident after ischemia/reperfusion and hypoxia/reoxygenation. Adenosine concentrations rose to a level of 1 µM in coronary effluent during hypoxic perfusion, but remained one order of magnitude lower in the interstitial fluid. There was only a small rise in the level during postischemic perfusion. In contrast, inosine peaked at over 10 µM in interstitial fluid during hypoxia and also during reperfusion, while effluent levels remained relatively unchanged at lower levels. We conclude that only inosine attains levels in the interstitial fluid of hypoxic and postischemic hearts that are sufficient to explain the activation of mast cells via stimulation of A3-type receptors.