On-Line Assessment (OLA) como preparación al Examen del Diploma Europeo de Anestesia y Cuidados Intensivos (EDAIC): estudio retrospectivo observacional sobre los resultados y el impacto sobre el examen Parte-I / On-Line Assessment (OLA) as a preparation for the European Diploma in Anaesthesiology and Intensive Care (EDAIC), a retrospective observational study on the results and the potential impact on the Part-I examination

Introducción: El Examen del Diploma Europeo de Anestesia y Cuidados Intensivos (EDAIC) es un diploma de la Sociedad Europea de Anestesia y Cuidados intensivos (ESAIC), obtenido tras aprobar dos exámenes, una primera parte escrita con preguntas de tipo test y una segunda parte oral estructurada. En 2011, otra prueba formativa en línea (el OnLine Assessment [OLA]) fue introducida para ayudar los candidatos a prepararse para el primer examen (EDAIC-I). Este estudio retrospectivo observacional fue diseñado para evaluar los resultados del OLA y su impacto sobre el EDAIC-I entre 2013 y 2019. Métodos: Después de obtener la autorización del comité examinador de la ESAIC, todos los resultados de los candidatos registrados para el OLA y/o el EDAIC-I entre 2013 y 2019 fueron incluidos. El número total de inscripciones y los resultados fueron analizados y comparados para ambas pruebas. Resultados: Más de 17.000 candidatos (17.401) presentaron cualquiera de los exámenes escritos del EDAIC. La tasa de aprobados en el EDAIC-I fue del 68,95%. La nota en el OLA aumentó de manera significativa en intentos sucesivos para el Paper A (Ciencias Básicas) (p = 0,006). La tasa global de aprobados en el EDAIC-I fue más alta en los candidatos que habían presentado el OLA antes (72,9 vs. 68,3%; OR: 1,25; IC 95% [1,12; 1,39]; p < 0,001). Los candidatos que fallaron en el primer intento al EDAIC-I repitieron más el examen si habían realizado el OLA (OR: 1.396, IC 95% [1.237; 1.574]; p < 0,001). Conclusión: El OLA fue asociado a un aumento de los resultados en ciencias básicas y de la tasa de aprobados en el EDAIC-I.(AU)

Background: The EDAIC is a diploma of the European Society of Anaesthesiology and Intensive Care (ESAIC). which is obtained after passing two a written MCQ-based (Part1) and a structured oral (part2) examinationIn 2011, a formative On-Line Assessment (OLA) was introduced to help candidates to prepare for EDAIC Part1 examination (EDAIC-I). This retrospective observational study evaluated the results of the OLA and its impact on the EDAIC-1 between 2013 and 2019. : Methods: After obtaining the authorisation from the ESAIC Examinations Committee, all the results of candidates registered to OLA and/or EDAIC-I between 2013 and 2019 were included. The total number of registrations and the results were analysed and compared for both. Results: Over 17,000 candidates (17,401) sat any of the written exams of the EDAIC. The overall pass-rate for the EDAIC-1 was 68.95%. The OLA score increased significantly with the number of attempts for Paper A (Basic Science) (p = 0.006). Overall success of the EDAIC-I was higher in candidates who took the OLA before (72.9% versus 68.3%; OR: 1.25; 95% CI [1.12; 1.39]; p< 0.001). Candidates who failed in their first attempt for EDAIC-I were more likely to sit the exam again if they had performed the OLA before (OR: 1.396, 95% CI [1.237; 1.574]; p< 0.001). Conclusion: The OLA was associated with an improvement of the results in basic science and success rate in the EDAIC-I.(AU)

On-Line Assessment (OLA) as a preparation for the European Diploma in Anaesthesiology and Intensive Care (EDAIC), a retrospective observational study on the results and the potential impact on the Part-I examination.

BACKGROUND: The EDAIC is a diploma of the European Society of Anaesthesiology and Intensive Care (ESAIC). which is obtained after passing two a written MCQ-based (Part1) and a structured oral (part2) examinationIn 2011, a formative On-Line Assessment (OLA) was introduced to help candidates to prepare for EDAIC Part1 examination (EDAIC-I). This retrospective observational study evaluated the results of the OLA and its impact on the EDAIC-1 between 2013 and 2019. METHODS: After obtaining the authorisation from the ESAIC Examinations Committee, all the results of candidates registered to OLA and/or EDAIC-I between 2013 and 2019 were included. The total number of registrations and the results were analysed and compared for both. RESULTS: Over 17,000 candidates (17,401) sat any of the written exams of the EDAIC. The overall pass-rate for the EDAIC-1 was 68.95%. The OLA score increased significantly with the number of attempts for Paper A (Basic Science) (p=0.006). Overall success of the EDAIC-I was higher in candidates who took the OLA before (72.9% versus 68.3%; OR: 1.25; 95% CI [1.12; 1.39]; p<0.001). Candidates who failed in their first attempt for EDAIC-I were more likely to sit the exam again if they had performed the OLA before (OR: 1.396, 95% CI [1.237; 1.574]; p<0.001). CONCLUSION: The OLA was associated with an improvement of the results in basic science and success rate in the EDAIC-I.

Pharmacokinetic Characterisation and Comparison of Bioavailability of Intranasal Fentanyl, Transmucosal, and Intravenous Administration through a Three-Way Crossover Study in 24 Healthy Volunteers.

BACKGROUND: For more than 60 years, the synthetic opioid fentanyl has been widely used in anaesthesia and analgesia. While the intravenous formulation is primarily used for general anaesthesia and intensive care settings, the drug's high lipophilic properties also allow various noninvasive routes of administration. Published data suggest that intranasal administration is also attractive for use as intranasal patient-controlled analgesia (PCA). A newly developed intranasal fentanyl formulation containing 47 µg fentanyl, intravenous fentanyl, and oral transmucosal fentanyl citrate were characterised, and bioavailability was compared to assess the suitability of the intranasal formulation for an intranasal PCA product. METHODS: 27 healthy volunteers were enrolled in a single-centre, open-label, randomised (order of treatments), single-dose study in a three-period crossover design. The pharmacokinetics of one intranasal puff of fentanyl formulation (47 µg, 140 mL per puff), one short intravenous infusion of 50 µg fentanyl, and one lozenge with an integrated applicator (200 µg fentanyl) were studied, and bioavailability was calculated. Blood samples were collected over 12 hours, and plasma concentrations of fentanyl were determined by HPLC with MS/MS detection. RESULTS: 24 volunteers completed the study. The geometric mean of AUC0-tlast was the highest with oral transmucosal administration (1106 h ∗ pg/ml, CV% = 32.86), followed by intravenous (672 h ∗ pg/ml, CV% = 32.18) and intranasal administration (515 h ∗ pg/ml, CV% = 30.10). C max was 886 pg/ml (CV% = 59.38) for intravenous, 338 pg/ml (CV% = 45.61) for intranasal, and 310 pg/ml (CV% = 29.58) for oral transmucosal administration. t max was shortest for intravenous administration (0.06 h, SD = 0.056), followed by intranasal (0.21 h, SD = 0.078) and oral transmucosal administration (1.20 h, SD = 0.763). Dose-adjusted absolute bioavailability was determined to be 74.70% for the intranasal formulation and 41.25% for the oral transmucosal product. In total, 38 adverse events (AEs) occurred. Fourteen AEs were potentially related to the investigational items. No serious AE occurred. CONCLUSION: Pharmacokinetic parameters and bioavailability of the investigated intranasal fentanyl indicated suitability for its intended use as an intranasal PCA option.

[Managing the pandemic-relocation concept for COVID-19 intensive care patients and non-COVID-19 intensive care patients in Baden-Württemberg]. / Die Pandemie bewältigen ­ Verlegungskonzept von COVID-19-Intensivpatienten und Non-COVID-19-Intensivpatienten in Baden-Württemberg.

BACKGROUND: A sharp rise in COVID-19 infections threatened to lead to a local overload of intensive care units in autumn 2020. To prevent this scenario a nationwide relocation concept was developed. METHODS: For the development of the concept publicly available infection rates of the leading infection authority in Germany were used. Within this concept six medical care regions (clusters) were designed around a center of maximum intensive care (ECMO option) based on the number of intensive care beds per 100,000 inhabitants. The concept describes the management structure including a structural chart, the individual tasks, the organization and the cluster assignment of the clinics. The transfers of intensive care patients within and between the clusters were recorded from 11 December 2020 to 31 January 2021. RESULT: In Germany and Baden-Württemberg, 1.5% of patients newly infected with SARS-CoV­2 required intensive care treatment in mid-December 2020. With a 7-day incidence of 192 new infections in Germany, the hospitalization rate was 10% and 28-35% of the intensive care beds were occupied by COVID-19 patients. Only 16.8% of the intensive care beds were still available, in contrast to 35% in June 2020. The developed relocation concept has been in use in Baden-Württemberg starting from 10 December 2020. From then until 7 February 2021, a median of 24 ± 5/54 intensive care patients were transferred within the individual clusters, in total 154 intensive care patients. Between the clusters, a minimum of 1 and a maximum of 15 (median 12.5) patients were transferred, 21 intensive care patients were transferred to other federal states and 21 intensive care patients were admitted from these states. The total number of intensive care patients transferred was 261. CONCLUSION: If the number of infections with SARS-CoV­2 increases, a nationwide relocation concept for COVID-19 intensive care patients and non-COVID-19 intensive care patients should be installed at an early stage in order not to overwhelm the capacities of hospitals. Supply regions around a leading clinic with maximum intensive care options are to be defined with a central management that organizes the necessary relocations in cooperation with regional and superregional rescue service control centers. With this concept and the intensive care transports carried out, it was possible to effectively prevent the overload of individual clinics with COVID-19 patients in Baden-Württemberg. Due to that an almost unchanged number of patients requiring regular intensive care could be treated.

Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine : A prospective, national, multicenter, non-interventional study-the HYPOTENS trial.

BACKGROUND: Sympathomimetic drugs are a therapeutic cornerstone for the management of hypotensive states like intraoperative hypotension (IOH). While cafedrine/theodrenaline (C/T) is widely used in Germany to restore blood pressure in patients with IOH, more research is required to compare its effectiveness with alternatives such as ephedrine (E) that are more commonly available internationally. METHODS: HYPOTENS (NCT02893241, DRKS00010740) was a prospective, national, multicenter, open-label, two-armed, non-interventional study that compared C/T with E for treatment of IOH. We describe a prospectively defined cohort of patients ≥50 years old with comorbidities undergoing general anesthesia induced with propofol and fentanyl. Primary objectives were to examine treatment precision, rapidity of onset and the ability to restore blood pressure without relevant increases in heart rate. Secondary endpoints were treatment satisfaction and the number of required additional boluses or other accompanying measures. RESULTS: A total of 1496 patients were included in the per protocol analysis. Overall, effective stabilization of blood pressure was achieved with both C/T and E. Post-hoc analysis showed that blood pressure increase from baseline was more pronounced with C/T. Fewer additional boluses or other accompanying measures were required in the C/T arm. The incidence of tachycardia was comparable between groups. Post-hoc analysis showed that E produced dose-dependent elevated heart rate values. By contrast, heart rate remained stable in patients treated with C/T. Physicians reported a higher level of treatment satisfaction with C/T, with a higher proportion of anesthetists rating treatment precision and rapidity of onset as good or very good when compared with E. CONCLUSION: Neither drug was superior in restoring blood pressure levels; however, post-hoc analyses suggested that treatment is more goal-orientated and easier to control with C/T. Heart rate was shown to be more stable with C/T and fewer additional interventions were required to restore blood pressure, which could have contributed to the increased treatment satisfaction reported by anesthetists using C/T.

[Clinical pharmacokinetics of anti-infective drugs in extracorporeal membrane oxygenation]. / Klinische Pharmakokinetik der Antiinfektiva bei extrakorporaler Membranoxygenierung.

Extracorporeal membrane oxygenation (ECMO) is becoming more and more clinically important. The extracorporeal circuit for membrane oxygenation consists of a pump, a membrane oxygenator and large volume tubing. The ECMO device forms an additional compartment, which can absorb drugs with high lipophilia and protein binding. Thus, ECMO affects the volume of distribution and the clearance. As a consequence, the pharmacokinetic-pharmacodynamic (pk-pd) target parameters cannot be achieved. The selection of an appropriate substance and the mode of application, combined with therapeutic drug monitoring (TDM), can significantly improve the therapeutic outcome of critically ill patients.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology

The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.(AU)

[Preoperative risk evaluation of adult patients prior to elective non-cardiac surgery: follow-up survey of the recommendations published in 2010]. / Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen: Follow-up-Umfrage zu den 2010 publizierten Empfehlungen.

BACKGROUND: The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine on preoperative evaluation of adult patients prior to elective, non-cardiac surgery published in November 2010 were the first practical and comprehensive guidelines for preoperative evaluation available to anesthetists in Germany. AIM: This study was carried out to analyze the state of implementation of these guidelines into clinical practice as well as changes in strategies for assessing perioperative risk from the viewpoint of anesthesia personnel in Germany. MATERIAL AND METHODS: A 25-item questionnaire concerning general characteristics of workplaces, cognizance, reasonability and convenience of the joint recommendations was developed as an online survey. Furthermore, changes in strategies for preoperative evaluation were polled. RESULTS: A total of 1,840 anesthetists completed the questionnaire. The results showed that 84.2 % were acquainted with the joint recommendations, 57.3 % evaluated them as completely reasonable and 18.2 % as partly reasonable. A total of 71.4 % indicated that the joint recommendations were implemented completely or partly in their department strategies for preoperative evaluation. From the viewpoint of personnel, anamnesis and physical examination were performed more frequently by 25.7 % while routine diagnostic testing was ordered less frequently by 39.1 %. Advantages by implementing the joint recommendations (e.g. simplification for medical staff and patients, decrease of costs, reduction of radiological examinations) were seen by 45.5 %. Problems, such as increasing expenditure of time and personnel due to implementation were mentioned by 20.3 %. CONCLUSION: The joint recommendations are well known and positively rated among anesthetists in Germany responding to the questionnaire reflecting an effective implementation process over the last 2 years. The anesthetists who completed the questionnaire stated that the use of the recommendations leads to a more reasonable approach in preoperative risk evaluation which contributes to an increase in patient safety and satisfaction.

Report on a study of fires with smoke gas development : determination of blood cyanide levels, clinical signs and laboratory values in victims.

BACKGROUND: This is a report on an international non-interventional study of patients exposed to fires with smoke development in closed rooms. The objective of the study was to document clinical symptoms, relevant laboratory values and blood cyanide concentrations from fire victims in order to confirm or rule out presumptive correlations between the individual parameters. MATERIALS AND METHODS: The study was conducted in five European countries with patients being included if they presented with the characteristic clinical signs, such as soot deposits and altered neurological status. Venous blood samples were taken from victims prior to administration of an antidote in all cases and determination of cyanide concentration was performed in a central laboratory using high performance liquid chromatography. RESULTS: Data from 102 patients (62 % male, average age 49 years) were included in the evaluation with no blood samples being available for analysis from 2 patients. In 25 patients the blood cyanide concentration was below the limit of detection of 1.2 µmol/l. Cyanide levels between 1.2 and 10 µmol/l were measured in 54 patients, 7 patients had values between 10 and 20 µmol/l, 4 patients between 20 and 40 µmol/l while levels above 40 µmol/l were determined in 10 patients. The results of the study could not demonstrate that the cyanide level was influenced either by the interval between smoke exposure and blood sampling or the duration presence at the fire scene. The following clinical signs or laboratory values were recorded as relevant for increased and possibly toxic cyanide levels: respiratory arrest, dyspnea, resuscitation requirement, tracheal intubation, respiratory support measures, low Glasgow coma scale (GCS) score and respiratory frequency. A correlation between cyanide concentration and the total amount of soot deposits on the face and neck, in the oral cavity and in expectoration was confirmed. A correlation between cyanide and carboxyhemoglobin (COHb) levels in the blood of fire victims was also confirmed. CONCLUSIONS: As long as it is not possible to immediately determine the blood cyanide concentration in patients exposed to fire with smoke development, a decreased GCS score, soot deposits particularly in expectoration, dyspnea and convulsions are to be regarded as risk markers for intoxication. In their presence immediate administration of hydroxocobalamin as an antidote is recommended.

[Modified rapid sequence induction for Caesarian sections : case series on the use of rocuronium and sugammadex]. / Modifizierte Blitzintubation im Kreißsaal : Fallserie zum Einsatz von Rocuronium und Sugammadex.

BACKGROUND: Aspiration is a feared complication of anesthesia and is accompanied by increased morbidity and mortality. Rapid sequence induction (RSI) describes the preferred procedure to perform endotracheal placement of the tubus in emergency cases of patients with an increased risk of aspiration of gastric contents. For more than 50 years RSI has consisted of the application of suxamethonium for neuromuscular blockade because of its fast onset and ultra short duration. Due to the serious side effects of suxamethonium attempts were made to find better alternative neuromuscular blocking drugs, e.g. rocuronium, to perform RSI. MATERIALS AND METHODS: In this small clinical series RSI was performed for general anesthesia of ten pregnant women for Caesarean sections using 1.0 mg/kgBW rocuronium for induction and maintaining deep relaxation until the end of surgery. For rapid reversal of the neuromuscular blockade to a train-of-four (TOF) ratio of 0.9, the µ-cyclodextrin sugammadex was administered at the end of surgery. Major and minor side effects, such as cardiac dysrhythmia, anaphylactic reactions, hoarseness and postoperative nausea and vomiting were documented. CONCLUSIONS: The combination of rocuronium and sugammadex for RSI combines rapid onset and rapid reversal of neuromuscular blockades with avoidance of serious side effects and very comfortable conditions for intubation in all cases. Minor side effects such as hoarseness, throat discomfort (in up to 30%) and myalgia (10%) for up to 48 h were documented.

A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery.

Deep neuromuscular blockade during certain surgical procedures may improve operating conditions. Sugammadex can be used to reverse deep neuromuscular blockade without waiting for spontaneous recovery. This randomised study compared recovery times from neuromuscular blockade induced by rocuronium 0.6 mg.kg(-1), using sugammadex 4 mg.kg(-1) administered at 1-2 post-tetanic count (deep blockade) or neostigmine 50 µg.kg(-1) (plus atropine 10 µg.kg(-1)) administered at the re-appearance of the second twitch of a train-of-four stimulation (moderate blockade), in patients undergoing laparoscopic surgery. The primary efficacy variable was the time from the start of sugammadex/neostigmine administration to recovery of the train-of-four ratio to 0.9. Patients receiving sugammadex recovered 3.4 times faster than patients receiving neostigmine (geometric mean (95% CI) recovery times of 2.4 (2.1-2.7) and 8.4 (7.2-9.8) min, respectively, p<0.0001). Moreover, 94% (62/66) of sugammadex-treated patients recovered within 5 min, vs 20% (13/65) of neostigmine-treated patients, despite the difference in the depth of neuromuscular blockade at the time of administration of both drugs. The ability to provide deep neuromuscular blockade throughout the procedure but still permit reversal at the end of surgery may enable improved surgical access and an enhanced visual field.

[Preoperative risk evaluation of adult patients for elective, noncardiac surgical interventions. Results of an on-line survey on the status in Germany]. / Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen. Ergebnisse einer Onlinebefragung zum Status in Deutschland.

BACKGROUND: While assessing the medical history and physical examination are the cornerstones of preoperative risk evaluation, the importance of "routine" testing has been critically discussed in recent studies. The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine for preoperative evaluation of adult patients prior to elective, non-cardiac surgery, which were published in November 2010, are the first comprehensive practice guidelines for preoperative evaluation in Germany. Aim of this study was to analyze former strategies for assessing perioperative risk at anaesthesia departments in Germany. METHODS: A 29-item questionnaire concerning general hospital characteristics, strategies for preoperative evaluation and cognizance of the joint recommendations was developed as an online survey. In particular the reasons for technical assessment were surveyed (i.e. routine, patient age or pre-existing conditions, risk of operation being performed). In certain questions multiple answers were permitted. All hospitals with departments of anaesthesiology in Germany were included. Data are presented as percentages. RESULTS: A total of 396 hospitals (35.6%) completed the questionnaire. Physical examination is not performed regularly (37%) but only when indicated by the medical history. Criteria for performing preoperative electrocardiograms are comorbidities of the cardiovascular (80.1%) and pulmonary systems (42.2%) as well as patient age (52.8%) and as routine measures (10.1%). Laboratory testing was performed as a routine (43.2%) because of patient age (52.8%) or pre-existing conditions (37.3%). Preoperative chest x-ray was carried out when the medical history or physical examination suggest intrathoracic pathologies (81.3%) or was based on patient age (35.9%). The majority of hospitals (89.1%) plan to implement the joint recommendations for preoperative evaluation in the future. CONCLUSION: According to the joint recommendations preoperative testing is more and more directed to patients with an increased perioperative risk which is clinically indicated by medical history and physical examination. However, routine or age-related medical testing is still a frequently used strategy. German medical societies should focus on advanced implementation strategies to change current practices in order to avoid unnecessary diagnostic procedures and to increase patient safety and satisfaction.

[Life-threatening acute chest syndrome with hemolytic crisis in sickle cell disease. Treatment using a venovenous extracorporeal membrane oxygenation (ECMO)]. / Lebensbedrohliches akutes Thoraxsyndrom mit hämolytischer Krise bei Sichelzellerkrankung.

HISTORY AND CLINICAL FINDINGS: A 28-year-old male patient with sickle cell disease developed a vasoocclusive crisis with an acute chest syndrome and severe lung failure. TREATMENT AND COURSE: After partial substitution transfusion the patient was successfully treated extracorporeal membrane oxygenation (ECMO). After 12 days he was weaned from the ECMO, 2 days later the patient's tracheostoma was removed. 19 days after the event the patient had recovered completely and was moved to a hospital in Paris from where he came. CONCLUSION: Apparently data is sparse regarding the use of ECMO for treatment of a life-threatening acute chest syndrome in sickle cell disease. However, the therapy approach seems to be promising and is worth considering in this particular situation.

Pre-operative fasting: a nationwide survey of German anaesthesia departments.

BACKGROUND: Shorter pre-operative fasting improves clinical outcome without an increased risk. Since October 2004, German Anaesthesiology Societies have officially recommended a fast of 2 h for clear fluids and 6 h for solid food before elective surgery. We conducted a nationwide survey to evaluate the current clinical practice in Germany. METHODS: Between July 2006 and January 2007, standardized questionnaires were mailed to 3751 Anaesthesiology Society members in leading positions requesting anonymous response. RESULTS: The overall response rate was 66% (n=2418). Of those, 2148 (92%) claimed familiarity with the new guidelines. About a third (n=806, 34%) reported full adherence to the new recommendations, whereas 1043 (45%) reported an eased fasting practice. Traditional Nil per os after midnight was still recommended by 157 (7%). Commonest reasons reported for adopting the new guidelines were: 'improved pre-operative comfort' (84%), and 'increased patient satisfaction' (83%); reasons against were: 'low flexibility in operation room management' (19%), and 'increased risk of aspiration' (13%). CONCLUSION: Despite the apparent understanding of the benefits from reduced pre-operative fasting, full implementation of the guidelines remains poor in German anaesthesiology departments.

[Ornithine transcarbamylase deficiency in adolescence and adulthood: first manifestation with life-threatening decompensation]. / Ornithintranscarbamylasemangel im Jugend- und Erwachsenenalter: Erstmanifestation mit lebensbedrohlicher Dekompensation.

BACKGROUND: Ornithine transcarbamylase (OTC) deficiency is the most frequent innate disorder of the urea cycle and is X-chromosome linked. The disease normally manifests itself shortly after birth and is fatal when untreated. Due to the different expression and X-chromosomal inheritance the manifestation of symptoms can appear later particularly in girls and young women. The first symptoms are non-specific signs of elevated cerebral pressure as a result of a hyperammonemia, which range from nausea and headache up to cerebral herniation with fatal outcome. Measurement of plasma ammonia levels is a simple yet important screening test for patients with unexpected stupor or delirium. CASE REPORTS: The two case reports show the clinical range from acute decompensation with acute cerebral herniation followed by fatal outcome to recovery under emergency therapy without substantial neurological deficits. THERAPY: Emergency treatment consists of symptomatic securing of vital parameters and an immediate reduction in the ammonia level using high calorie, protein-free nutrition to avoid catabolism together with administration of arginine, benzoate or phenyl butyrate. In cases of coma with severe cerebral edema and the threat of a herniation reaction or excessive ammonia levels, emergency hemodialysis must be immediately carried out. CONCLUSIONS: In the clinical routine it is extremely important to consider a metabolic defect at an early phase and among others to determine the ammonia level so that the appropriate treatment can be instigated in time.

Muscle relaxant use for tracheal intubation in pediatric anaesthesia: a survey of clinical practice in Germany.

OBJECTIVES: Aim of this Germany-wide study was to evaluate the use and application customs of neuromuscular blocking drugs (NMBDs) for tracheal intubation in children of age 5 years or younger. MATERIAL AND METHODS: In the year 2005, a total of 3260 questionnaires were sent out to all heads of anesthesia departments at all types of hospitals as well as ambulatory anesthesia centers in Germany. The fields covered by the questionnaire were regarding institutional size, amount of general anesthesia and specifically pediatric cases, number of intubations and NMBDs used, frequency of use of the individual relaxants and techniques utilized when administering muscle relaxants. RESULTS: Of the sent-out questionnaires 66.9% could be analyzed: 82% of hospitals use 1-3 muscle relaxants in children; 91% of the ambulatory anesthesia centers use a repertoire of 1-2 neuromuscular blockers for pediatric cases. However, general anesthesia with tracheal intubation in children is often induced without using any NMBD at all. Mivacurium is the predominantly used NMBD for pediatric intubation in Germany. In contrast, the use of succinylcholine is far less in ambulatory anesthesia centers than in hospitals. Despite controversial discussion, precurarization, priming, and timing are still utilized in German anesthesia practice. CONCLUSION: In Germany, mivacurium, with its favorable pharmacologic profile for short cases, is the predominantly used NMBD for pediatric tracheal intubation. Despite the known adverse effects of intubation without muscle relaxation, this technique is also wide-spread, especially among German anesthetists in ambulatory anesthesia centers. Surveys like these are important to determine a status quo of use and application customs of NMBDs in pediatric anesthesia and provide a basis for numerous other studies.