[Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. / Behandlung im Voraus Planen ­ Weiterentwicklung der Patientenverfügung : Was die Internistin/der Internist dazu wissen muss.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

[Short version of the 2nd edition of the German-Austrian S3 guidelines "Cardiogenic shock complicating myocardial infarction-Diagnosis, monitoring and treatment"]. / Kurzversion der 2. Auflage der deutsch-österreichischen S3-Leitlinie "Infarkt-bedingter Kardiogener Schock ­ Diagnose, Monitoring und Therapie".

BACKGROUND: The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects. METHODS: Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions. RESULTS: A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.

[Advance Care Planning-further development of the patient advance directive : What the anesthetist must know]. / Behandlung im Voraus Planen ­ Weiterentwicklung der Patientenverfügung : Was die Anästhesistin/der Anästhesist dazu wissen muss.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

Preoperative evaluation of adult patients before elective, noncardiothoracic surgery : Joint recommendation of the German Society of Anesthesiology and Intensive Care Medicine, the German Society of Surgery, and the German Society of Internal Medicine.

Evaluation of the patient's medical history and a physical examination are the cornerstones of risk assessment prior to elective surgery, and may help to optimize the patient's preoperative medical condition and guide perioperative management. Whether performance of additional technical tests (e. g., blood chemistry, electrocardiography, spirometry, chest x­ray) can contribute to reduction of the perioperative risk is often not well known or controversial. Similarly, there is considerable uncertainty among anesthesiologists, internists, and surgeons with respect to perioperative management of the patient's long-term medication. Therefore, the German Scientific Societies of Anesthesiology and Intensive Care Medicine (DGAI), Internal Medicine (DGIM), and Surgery (DGCH) have joined to elaborate recommendations on the preoperative evaluation of adult patients prior to elective noncardiothoracic surgery which were initially published in 2010. These recommendations have now been updated based on the current literature and existing international guidelines. In the first part, the general principles of preoperative evaluation are described (part A). The current concepts for extended evaluation of patients with known or suspected major cardiovascular disease are presented in part B. Finally, the perioperative management of patients' long-term medication is discussed (part C). The concepts proposed in these interdisciplinary recommendations endorsed by the DGAI, DGIM, and DGCH provide a common basis for structured preoperative risk assessment and management. These recommendations aim to ensure that surgical patients undergo a rational preoperative assessment and, at the same time, aim to avoid unnecessary, costly, and potentially dangerous testing. The joint recommendations reflect the current state-of-the-art knowledge as well as expert opinions, because scientific-based evidence is not always available. These recommendations will be subject to regular re-evaluation and updating when new validated evidence becomes available.Contribution available free of charge by "Free Access".

[Considerations concerning the perioperative use of metamizole]. / Überlegungen zum perioperativen Einsatz von Metamizol.

BACKGROUND: The non-opioid analgesic metamizole (dipyrone) is approved for the treatment of severe pain and is often used in the perioperative period. As it can cause agranulocytosis, a severe adverse event, its perioperative administration is controversially discussed. OBJECTIVE: Is there enough evidence for a high risk of metamizol-induced agranulocytosis (MIA)? What are the consequences of its perioperative use with respect to the risk profiles of alternative analgesics? MATERIAL AND METHODS: Rapid review of the literature on the risk of MIA and adverse effects of non-opioid analgesics. RESULTS: The incidence of MIA is estimated to be one case per million inhabitants per year. The risk seems low compared to other drugs associated with a risk of agranulocytosis, such as antithyroid drugs and ticlopidine. The risk profile of metamizole concerning hepatotoxicity, nephrotoxicity, bleeding and cardiovascular adverse effects is favorable compared to other non-opioid analgesics. None of the non-opioid analgesics are licensed to be administered intraoperatively. CONCLUSION: The perioperative use of metamizole is possible after a thorough evaluation of the indications as it provides good analgesia with a generally favorable side effect profile and is administered intravenously. The risk of agranulocytosis is small but needs to be mentioned during patient informed consent in order to optimize early recognition. Intraoperative administration aims at reducing the expected severe postoperative pain. A documentation and justification for the evaluation of the indications are recommended.

Defibrillator charging before rhythm analysis causes peri-shock pauses exceeding guideline recommended maximum 5 s : A randomized simulation trial.

INTRODUCTION: Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged. METHODS: This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand. RESULTS: A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07). CONCLUSION: Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups.

[Preoperative evaluation of adult patients before elective, noncardiothoracic surgery : Joint recommendation of the German Society of Anesthesiology and Intensive Care Medicine, the German Society of Surgery, and the German Society of Internal Medicine]. / Präoperative Evaluation erwachsener Patienten vor elektiven, nicht Herz-Thorax-chirurgischen Eingriffen : Gemeinsame Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, der Deutschen Gesellschaft für Chirurgie und der Deutschen Gesellschaft für Innere Medizin.

Evaluation of the patient's medical history and a physical examination are the cornerstones of risk assessment prior to elective surgery and may help to optimize the patient's preoperative medical condition and to guide perioperative management. Whether the performance of additional technical tests (e. g. blood chemistry, ECG, spirometry, chest x­ray) can contribute to a reduction of perioperative risk is often not very well known or is controversial. Similarly, there is considerable uncertainty among anesthesiologists, internists and surgeons with respect to the perioperative management of the patient's long-term medication. Therefore, the German Scientific Societies of Anesthesiology and Intensive Care Medicine (DGAI), Internal Medicine (DGIM) and Surgery (DGCH) have joined to elaborate recommendations on the preoperative evaluation of adult patients prior to elective, noncardiothoracic surgery, which were initially published in 2010. These recommendations have now been updated based on the current literature and existing international guidelines. In the first part the general principles of preoperative evaluation are described (part A). The current concepts for extended evaluation of patients with known or suspected major cardiovascular disease are presented in part B. Finally, the perioperative management of patients' long-term medication is discussed (part C). The concepts proposed in these interdisciplinary recommendations endorsed by the DGAI, DGIM and DGCH provide a common basis for a structured preoperative risk assessment and management. These recommendations aim to ensure that surgical patients undergo a rational preoperative assessment and at the same time to avoid unnecessary, costly and potentially dangerous testing. The joint recommendations reflect the current state-of-the-art knowledge as well as expert opinions because scientific-based evidence is not always available. These recommendations will be subject to regular re-evaluation and updating when new validated evidence becomes available.

[ASA classification : Transition in the course of time and depiction in the literature]. / ASA-Klassifikation : Wandel im Laufe der Zeit und Darstellung in der Literatur.

The American Society of Anesthesiologists classification of physical status (ASA PS) is a widely used system for categorizing the preoperative status of patients. The ASA class is a good independent predictor of perioperative morbidity and mortality. The definitions of the ASA classes have been amended several times since 1941, resulting in inconsistent and confusing usage in the current literature. Conflicting definitions of ASA PS exist, particularly for classes III, IV and V. The high variability of individual classifications by different anesthesiologist, however, can be explained by the previous lack of examples for diagnoses. In 2014, the ASA has added a catalogue of examples for a simplified definition for classification of the ASA PS. This has so far received limited attention in German-speaking countries. This article describes the transition of the ASA classification over the past 75 years und summarizes the currently valid definitions.

[Structured patient handovers in perioperative medicine : Rationale and implementation in clinical practice]. / Strukturierte Patientenübergabe in der perioperativen Medizin : Rationale und Umsetzung in der klinischen Praxis.

Clear and consistent communication is pivotal for well-functioning teamwork, in operating theatres as well as intensive care units. However, patient handovers significantly vary between specialties and locations. If communication is not well structured, it might increase the risk for mishaps and malpractice. Therefore, implementing structured handover protocols is pivotal. The perioperative setting is a high-risk environment that is prone to communication failures due to operational design (frequent change of shift due to working time restrictions) and a high work load and multitasking (operating room management, short surgery times, concurrent emergencies). Hence teamwork in the operating room and intensive care unit requires clear and consistent communication. In the perioperative setting, the patient is transferred several times: from the ward to operating room, to recovery, intermediate care/intensive care unit and back to normal ward. This necessitates multiple handovers. Since 2005, the World Health Organization (WHO) requests a structured handover concept that processes all relevant information in a predefined order. The SBAR concept (situation, background, assessment, recommendation) is an intuitive communication concept that can improve quality of patient handovers. This underlines the clinical relevance of a structured handover concept that leads to improved outcomes for every patient.In this review, basic measures for a clear and consistent communication are presented. These are pivotal for an effective teamwork and for ensuing patient safety. Furthermore, we will focus on possibilities to implement structured approaches but also on potential barriers of implementation. Communication failure among different health care providers can be identified more easily and hopefully can be eliminated.

[Recommendations of the German Society of Anaesthesiology and Intensive Care Medicine on structured patient handover in the perioperative phase : SBAR concept]. / Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin zur strukturierten Patientenübergabe in der perioperativen Phase : SBAR-Konzept.

Teamwork in the operating room and in the intensive care unit necessitates clear and precise communication; however, interruptions in communication frequently occur, especially in the perioperative phase. Patient are particularly susceptible to deficits in communication due to higher stress peaks, simultaneous admission of several patients and concomitant treatment of emergency cases etc. The German Society of Anaesthesiology and Intensive Care Medicine (DGAI) therefore recommends the implementation of the so-called SBAR concept (S: "situation", B: "background", A: "assessment", R: "recommendation") for standardization of patient handover. This concept was originally developed for high-risk areas and organizations with the aim of guaranteeing a rapid, effective and consistent transfer of information.

Recommendations of the German Association of Anesthesiology and Intensive Care Medicine (DGAI) on structured patient handover in the perioperative setting : The SBAR concept.

Teamwork in the operating room and in the intensive care unit necessitates clear and precise communication; however, interruptions in communication frequently occur, especially in the perioperative phase. Patients are particularly susceptible to deficits in communication, e.g. due to higher stress peaks, simultaneous admission of several patients and concomitant treatment of emergency cases. The German Society of Anesthesiology and Intensive Care Medicine (DGAI) therefore recommends the implementation of the so-called SBAR concept (S situation, B background, A assessment, R recommendation) for standardization of patient handover. This concept was originally developed for high-risk areas and organizations with the aim of guaranteeing a rapid, effective and consistent transfer of information.

[S1 guidelines on airway management]. / S1-Leitlinie Atemwegsmanagement.

Since the publication of the first german guidelines on airway management in 2014, new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

S1 guidelines on airway management : Guideline of the German Society of Anesthesiology and Intensive Care Medicine.

Since the publication of the first German guidelines on airway management in 2004 new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

[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.

German guidelines for airway management 2023.

The German airway management guidelines are intended to serve as an orientation and decision-making aid and thus contribute to the optimal care of patients undergoing anesthesiologic- and intensive medical care. As part of the pre-anesthesiologic evaluation, anatomical and physiological indications for difficult mask ventilation and intubation shall be evaluated. This includes the assessment of mouth opening, dental status, mandibular protrusion, cervical spine mobility and existing pathologies. The airway shall be secured while maintaining spontaneous breathing if there are predictors or anamnestic indications of difficult or impossible mask ventilation and/or endotracheal intubation. Various techniques can be used here. If there is an unexpectedly difficult airway, a video laryngoscope is recommended after unsuccessful direct laryngoscopy, consequently a video laryngoscope must be available at every anesthesiology workplace. The airway shall primarily be secured with a video laryngoscope in critically ill- and patients at risk of aspiration. Securing the airway using translaryngeal and transtracheal techniques is the "ultima ratio" in airway management. The performance or supervision of airway management in the intensive care unit is the responsibility of experienced physicians and nursing staff. Appropriate education and regular training are essential. Clear communication and interaction between team members are mandatory before every airway management procedure. Once the airway has been secured, the correct position of the endotracheal tube must be verified using capnography.

The limit of anemia tolerance during hyperoxic ventilation with pure oxygen in anesthetized domestic pigs.

BACKGROUND: During acellular replacement of an acute blood loss, hyperoxic ventilation (HV) increases the amount of O2 physically dissolved in the plasma and thereby improves O2 supply to the tissues. While this effect could be demonstrated for HV with inspiratory O2 fraction (FiO2) 0.6, it was unclear whether HV with pure oxygen (FiO2 1.0) would have an additional effect on the physiological limit of acute normovolemic anemia. METHODS: Seven anesthetized domestic pigs were ventilated with FiO2 1.0 and subjected to an isovolemic hemodilution protocol. Blood was drawn and replaced by a 6% hydroxyethyl starch (HES) solution (130/0.4) until a sudden decrease of total body O2 consumption (VO2) indicated the onset of O2 supply dependency (primary endpoint). The corresponding hemoglobin (Hb) concentration was defined as 'critical Hb' (Hbcrit). Secondary endpoints were parameters of myocardial function, central hemodynamics, O2 transport and tissue oxygenation. RESULTS: HV with FiO2 1.0 enabled a large blood-for-HES exchange (156 ± 28% of the circulating blood volume) until Hbcrit was met at 1.3 ± 0.3 g/dl. After termination of the hemodilution protocol, the contribution of O2 physically dissolved in the plasma to O2 delivery and VO2 had significantly increased from 11.7 ± 2 to 44.2 ± 9.7% and from 29.1 ± 4.2 to 66.2 ± 11.7%, respectively. However, at Hbcrit, cardiovascular performance was found to have severely deteriorated. CONCLUSION: HV with FiO2 1.0 maintains O2 supply to tissues during extensive blood-for-HES exchange. In acute situations, where profound anemia must be tolerated (e.g. bridging an acute blood loss until red blood cells become available for transfusion), O2 physically dissolved in the plasma becomes an essential source of oxygen. However, compromised cardiovascular performance might require additional treatment.