Präoperative Evaluation erwachsener Patienten vor elektiven,nicht Herz-Thorax-chirurgischen Eingriffen

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 x?ray) 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.     

De ratione temporis

Objectives

Early carotid endarterectomy (CEA) is recommended for symptomatic carotid artery stenosis with preventive benefit, so it should be performed within 14 days. The risk of recurrent stroke can be reduced if very urgent surgery (<48 h) is performed, but can be—according to newer studies—accompanied by a significantly increased perioperative risk. The aim of this study is to analyze the perioperative outcome of very early CEA within 48 h. In particular we want to identify variables associated with a perioperative risk and provide some modifications to decrease any risk factors.

Methods

We retrospectively analyzed data of 459 symptomatic patients with ocular or cerebral TIA. Patients were divided according to time interval between onset of symptoms and surgery 0–2 days, 3–14 days, and 15–180 days. Outcome event was assessed a persisting stroke or death within 30 days after surgery.

Results

Very early CEA was performed in 44 (9.6?%) patients. Overall 25 patients (7.4?%) suffered any perioperative stroke or death, divided into subgroups 3 (6.8?%) by day 2, 10 (6.8?%) by day 14, and 12 (4.5?%) by day 180. We did not find any significance between a higher perioperative risk and timing of CEA. Solely an intensified antiplatelet therapy was associated with a very early CEA.

Conclusions

In contrast to recent registry analyses, our data show that very early prophylactic CEA in symptomatic patients can be performed without any increased procedural risk. More intensified antiplatelet therapy may be a reason for reduced thromboembolic strokes.

     

Managing the perioperative patient on direct oral anticoagulants

Purpose

Patients are increasingly treated with direct oral anticoagulants (DOACs) for the prevention of stroke due to non-valvular atrial fibrillation and for the treatment of venous thromboembolism. When these patients present for urgent or emergent surgical procedures, they present a challenge to the anesthesiologist who must manage perioperative risk due to anticoagulation. The purpose of this module is to review the literature surrounding the perioperative management of DOACs. Timing, laboratory monitoring, and availability of reversal agents are important considerations to optimize patients being treated with DOACs who require emergent surgery.

Principal findings

Laboratory tests are not recommended for routine monitoring of DOACs since they do not correlate well with anticoagulant activity. Most widely available laboratory tests lack the sensitivity to detect anticoagulant effects at low plasma concentrations. However, a normal thrombin time for dabigatran excludes clinically significant drug levels. If the risk of bleeding is judged to be high because of a recent dose of DOAC, various options are available to mitigate bleeding. When possible, surgery should be delayed for at least 12 hr after the last dose of DOAC. Activated charcoal may mitigate the anticoagulant effect caused by DOACs if administered less than two hours after the drug was ingested. Four-factor prothrombin complex concentrates (PCCs) may be useful to reduce life-threatening bleeding associated with factor Xa inhibitors. Activated PCCs have been shown to reverse abnormal coagulation tests associated with all DOACs, but there is a lack of reported evidence of clinical benefit. Idarucizumab is a specific antidote that is effective for reversal of anticoagulation due to dabigatran. An antidote for rivaroxaban and apixaban (andexanet alfa) as well as a universal antidote for all DOACs and heparin (PER977) are in clinical development.

Conclusion

Perioperative management of anticoagulation due to DOACs is a growing concern as the number of patients prescribed these medications increases each year. These patients can be safely optimized for urgent or emergent surgery by giving appropriate consideration to timing, monitoring, and reversal agents.

     

Vorwärmung entsprechend der „S3 Leitlinie Vermeidung von unbeabsichtigter perioperativer Hypothermie 2014“

Background

Inadvertent perioperative hypothermia, which is defined as a core body temperature of less than 36.0?°C, can have serious consequences in surgery patients. These include cardiac complications, increased blood loss, wound infections and postoperative shivering; therefore, the scientific evidence that inadvertent perioperative hypothermia should be avoided is undisputed and several national guidelines have been published summarizing the scientific evidence and recommending specific procedures. The German AWMF guidelines were the first to emphasize the importance of prewarming for surgery patients to avoid inadvertant perioperative hypothermia; however, in contrast to intraoperative warming, prewarming is so far not sufficiently implemented in clinical practice in many hospitals. Furthermore, a recent study has questioned the effectiveness of prewarming.

Objective

The aim of this retrospective investigation was to evaluate the hypothermia rates that can be achieved when prewarming in the anesthesia induction room is introduced into the clinical practice and performed in addition to intraoperative warming.

Material and methods

The ethics committee of the Medical Faculty of the Martin Luther University Halle Wittenberg gave approval for data storage and retrospective data analysis from the anesthesia database. According to the existing local standard operating procedure, prewarming with forced air was performed in addition to intraoperative warming in the anesthesia induction room in 3899 patients receiving general anesthesia with a duration of 30?min or longer from January 2015 to December 2016. The results were compared with a control group of 3887 patients from July 2012 to August 2014 who received intraoperative warming but were not subjected to prewarming. Tracheal intubation was carried out in all patients and temperature measurements after the induction of anesthesia were performed using esophageal, urinary catheter or intra-arterial temperature probes.

Results

The mean duration of prewarming was 25?min in the treatment group. Patients subjected to prewarming showed an intraoperative hypothermia rate of 15.8% and a postoperative hypothermia rate of 5.1%. Patients without prewarming showed an intraoperative hypothermia rate of 30.4% and a postoperative hypothermia rate of 12.4%. This means a 52% reduction of the intraoperative hypothermia rate and a 41% reduction of the postoperative hypothermia rate for patients who received prewarmimg (p < 0.0001). Multivariate logistic regression revealed that the lack of prewarming was independently associated with intraoperative hypothermia with an odds ratio of 2.5 (95% confidence interval CI 2.250–2.841; p < 0.0001) and postoperative hypothermia with an odds ratio of 2.8 (95% CI 2.316–3.277; p < 0.0001).

Conclusion

Prewarming, as recommended in the AWMF guidelines, resulted in a significant and clinically relevant reduction in the incidence of inadvertent perioperative hypothermia; therefore, prewarming can still be regarded as an effective method to avoid perioperative hypothermia. Hypothermia rates of 15.8% intraoperatively and 5.1% postoperatively can be achieved in clinical practice, when prewarming is performed in addition to intraoperative warming in the anesthesia induction room directly before the start of surgical procedures.

     

Strukturierte Patientenübergabe in der perioperativen Medizin

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.     

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.     

Die rheumatische Instabilität der Halswirbelsäule

Background

The involvement of the cervical spine in rheumatoid arthritis (RA) continues to be of clinical importance even in this age of biologics. Pathophysiological changes begin with an isolated atlantoaxial subluxation and may progress to a complex craniocervical and subaxial instability. The onset of cervical myelopathy can occur at any time and leads to a deterioration of the prognosis for the patient.

Therapy

Treatment of the rheumatoid cervical spine should be aimed at improvement of the symptoms and prevention of further progress of the disease. In the case of instability, this is only possible by surgical treatment. The increasing usage of biological agents has led to a change in the clinical picture of the cervical involvement in RA patients. There are fewer patients presenting with isolated atlantoaxial instability. In contrast, the number of patients with complex craniocervical and/or subaxial instabilities is increasing. Complex cervical instabilities may require a longer fusion from the occiput to the upper thoracic spine. Modern operative techniques make this complex surgery also possible in severely disabled patients with a high comorbidity.

     

Management der perioperativen Myokardischämie

Patients undergoing vascular surgery are often affected by a much higher cardiac risk profile. Cardiac events in peripheral arterial disease (PAD) patients occur not only more frequently than in non-PAD patients but are also associated with a poorer outcome. Despite a similar underlying pathogenesis, PAD patients receive less pharmaceutical treatment than patients with known coronary artery disease (CAD). If certain risk factors for CAD are present, preoperative cardiology diagnostic testing and if necessary therapy is recommended. When a perioperative myocardial infarction is suspected, an electrocardiogram (ECG) should immediately be carried out. In the case of ST segment elevation myocardial infarction, a percutaneous coronary intervention (PCI) is performed without waiting for the blood test results. If a non-ST segment elevation myocardial infarction is present, further evaluation includes (serial) blood tests for troponin, a cardiac biomarker. In addition to a type 1 myocardial infarction, which is caused by rupture of plaque, a type 2 myocardial infarction must also be taken into consideration, which can arise due to an imbalance between oxygen needs and increased consumption even in the absence of plaque rupture (e.g. in cases of significant coronary artery stenosis and coronary artery spasm). Coronary angiography is performed on an individual basis depending on the risk-benefit assessment. Medicinal therapy of myocardial infarction includes dual platelet inhibition and anticoagulation. Other potentially life-threatening diseases, such as pulmonary embolism and aortic dissection have to be taken into account as differential diagnoses in acute situations.     

Indikationsprüfung neuer Armprothesen

Despite inceasing efforts at prevention, injuries are still a part of professional sport and an injury-free season is not to be expected in the four largest team sports in Germany, football, handball, basketball and ice hockey. Concepts for the prevention of relapse injuries as well as secondary and tertiary prevention programs are therefore necessary aspects of the rehabilitation process in competitive sports. Regardless of the rehabilitation phase, whether return to activity, return to sport, return to play or return to competition, the verification of physical and mental performance is an essential criterion for ensuring optimal progress. If the entire rehabilitation process is considered, the successive increase in load is a major challenge in all phases. It is important to avoid the impact of intensity and volume increases of more than 10% on the way to regain the preinjury level. Individual indicators from a preinjury screening provide an ideal orientation to determine whether a player is able to compete or not. In addition to consideration of the physiological healing process, the decisive criterion for achieving the “return to milestone” should be the performance capacity, adapted and related to the rehabilitation phase. As an example, a consensus for functional tests was defined in the rehabilitation after an anterior cruciate ligament reconstruction. In addition to a preliminary clinical examination, requirements were defined for postural control, jumping and landing capacity before and after fatigue provocation as well as speed and agility.     

Orale Antikoagulanzien

Vitamin K antagonists (VKA) and heparins have been standard anticoagulants over the past decades. They are considered effective and safe but several drawbacks led to the development of new oral anticoagulants. These inhibit specifically either thrombin or factor Xa, have a short half-life, are characterized by fixed-dose administration and routine coagulation monitoring is not required. Direct oral anticoagulants (DOACs) are used increasingly more in patients with non-valvular atrial fibrillation or in the treatment or secondary prophylaxis of venous thromboembolism. In cases of unexpected bleeding or urgent surgery specific antagonist treatment could be necessary but specific antidotes are not yet available. Currently, there are only few laboratories which offer specific coagulation tests for monitoring DOACs; however, DOACs considerably influence coagulation tests and make interpretation difficult. This article gives an overview of oral anticoagulants and possibilities for monitoring as well as recommendations for the management of bleeding complications and perioperative strategies for patients treated with oral anticoagulants.     

Komplikationen in der orthopädischen Rheumatologie – Besonderheiten operativer Verfahren

The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are still necessary in many patients but a change in surgical indications could be observed. The previously predominant synovectomy of inflamed rheumatic joints is now reduced to a few so-called rebellious joints with persistent inflammation. Joint-preservation and tenoplasty are standard surgical procedures requiring a specific approach including potential complications. The basic immunosuppressive medication has to be considered for all rheumatological interventions. Recommendations extensively evaluate the risk profile of immunosuppressants. The available clinical data are difficult to assess and incomplete. Advances in modern joint replacement procedures have increased the quality of life of patients. Compared to degenerative osteoarthritis, patients with rheumatism tend to present at a lower age, with poorer bone quality and have an increased risk for bacterial joint infections. In cases of a multilocular rheumatoid manifestation including all joints of the extremities, joint replacement specifics need to be taken into account. In patients with rheumatic diseases the mechanical stability of joint replacements, revision options, potential risk of joint infections and periprosthetic fractures vary sometimes considerably from patients with degenerative osteoarthritis. Missing clinical signs of joint infection despite a life-threatening, possibly multilocular dissemination of the disease due to immunosuppressants represents a particular challenge with respect to the diagnostics and treatment. The confusion of this with a rheumatic exacerbation might lead to general septicemia with a high mortality.     

Evaluation eines einfachen Testverfahrens in der ambulanten Sturzprävention

Background

An individual’s risk of falling is generally difficult to detect and it is likely to be underestimated. Thus, preventive measures are challenging and they demand sufficient integration and implementation into aftercare and outpatient management. The Aachen Falls Prevention Scale (AFPS) is a quick and easy tool for patient-driven fall risk assessment. Older adults’ risk of falling is identified in a suitable manner and they then have the opportunity to independently assess and monitor their risk of falling.

Objectives

The aim of the current study was to evaluate the AFPS as a simple screening tool in geriatric trauma patients via the identification of influencing factors, e.g. objective or subjective fall risk, fear of falling (FOF) and demographic data. In this context, we investigated older adults’ willingness to take part in special activities concerning fall prevention.

Methods

Retrospectively, all patients over 70 years of age who received in-hospital fracture treatment between July 2014 and April 2016 were analyzed at a level I trauma center. After identification of 884 patients, participants completed a short questionnaire (47 questions, yes/no, Likert scale) comprising the AFPS. A history of falls in the past year was considered an indicator of a balance disorder. In addition, ambulant patients were invited to participate between July and August 2016.

Results

In total, 201 patients (mean 80.4 years, range 63–97 years) performed a self-assessment based on the AFPS. After steps 1 and 2 of the AFPS had been completed, 95 (47%) participants rated their subjective risk of falling as high (more than 5 points). Of the participants 84 (42%) were objectively classified as “fallers” with significant effects on their AFPS evaluation and rating of their subjective risk of falling. Furthermore, 67% of the participants identified a general practitioner as their main contact person, and 43% of the respondents viewed the AFPS as a beneficial screening tool in fall risk evaluation (8% negative attitudes). Only 12% of the participants could imagine using the AFPS app version as a feasible option.

Conclusion

It would be advantageous to pretest at-risk individuals in their environment using a simple self-assessment approach, with the main purpose of identifying potential balance problems. With this approach, cost savings in the healthcare system are possible, combined with a higher health-related quality of life in the geriatric population.

     

Die Rolle des Krankenhauses bei Bedrohungslagen

Hospitals play a major role in the population’s medical care, especially during terrorist attacks or other life-threatening mass casualty incidents. They are a key element in the evacuation of patients from an unsafe environment to a place of definitive medical treatment The basic principle of the medical emergency response to threatening situations of this kind is the rapid evacuation of the most seriously injured patients to the hospital emergency room. Therefore, hospitals need to deal with a large number of patients in a short period of time. In order to successfully manage such situations, hospitals need to be prepared and a comprehensive emergency plan is crucial tool. Effective measures include triage, the principals of tactical abbreviated surgery care, and a management strategy for personnel and material resources.     

Teledermatologie und künstliche Intelligenz

Telemedicine with the special application of teledermatology (eHealth) is the use of telecommunication technologies to exchange medical information for diagnostics, consultation, therapy and teaching. Using artificial intelligence (AI), machines can learn and thus be used flexibly under changing environmental conditions. Teledermatology and AI-supported mobile image analysis systems as part of eHealth are expected to have a significant potential to improve prevention, diagnostics, therapy adherence and follow-up of patients with (impending) occupational skin diseases. Dermatological teleconsultation could help occupational physicians and company physicians in the care of workers in high-risk occupations, as well as in skin cancer screening of outdoor workers, thereby contributing to a better prevention or recognition of an occupational disease. Modern mobile smartphone apps supported by AI technologies could improve self-monitoring of workers in high-risk occupations, early occupational health intervention and dermatological therapy counselling.     

Enoxaparin Versus Direct Oral Anticoagulants for Venous Thromboembolism in Asians Undergoing Total Knee Arthroplasty: A Meta-Analysis and Systematic Review

BackgroundThe introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study.MethodsThe review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included.ResultsFive studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33).ConclusionDOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist.     

Konfliktmatrix

Background

In business conflicts have long been known to have a negative effect on costs and team performance. In medicine this aspect has been widely neglected, especially when optimizing processes for operating room (OR) management. In the multidisciplinary setting of OR management, shortcomings in rules for decision making and lack of communication result in members perceiving themselves as competitors in the patient’s environment rather than acting as art of a multiprofessional team. This inevitably leads to the emergence and escalation of conflicts.

Objective

We developed a conflict matrix to provide an inexpensive and objective way for evaluating the level of escalation of conflicts in a multiprofessional working environment, such as an OR.

Material and methods

The senior members of all involved disciplines were asked to estimate the level of conflict escalation between the individual professional groups on a scale of 0–9. By aggregating the response data, an overview of the conflict matrix within this OR section was created.

Results

No feedback was received from 1 of the 11 contacted occupational groups. By color coding the median, minimum and maximum values of the retrieved data, an intuitive overview of the escalation levels of conflict could be provided. The value range of all feedbacks was between 0 and 6. Estimation of the escalation levels differed widely within one category, showing a range of up to 6 (out of 6) levels.

Conclusion

The presented assessment using a conflict matrix is a simple and cost-effective method to assess the conflict landscape, especially in multidisciplinary environments, such as OR management. The chance of conflict prevention or the early recognition of existing conflicts represents an enormous potential for cost and risk saving and might have positive long-term effects by building a culture of conflict prevention at the workplace and a positive influence on interdisciplinary cooperation in this working environment.

     

Der Herzkathetertisch ist nicht der OP-Tisch

Background

Patients undergoing cardiac surgery need extensive and invasive monitoring, which needs to be individually adapted for each patient and requires a diligent risk-benefit analysis. The use of a pulmonary artery catheter (PAC) seems to be justifiable in certain cases; therefore, the preoperative diagnosis of pulmonary hypertension represents an indication for perioperative monitoring with PAC in the S3 guidelines of the German Society for Anesthesiology and Intensive Care Medicine (DGAI). In many cases, however, this preoperative diagnosis cannot be confirmed intraoperatively.

Objective

We wanted to find out whether this is just an impression or whether there actually are significant differences between preoperative, intraoperative and postoperative pulmonary artery pressures.

Material and methods

After obtaining ethical approval, we retrospectively compared the pulmonary pressures of cardiac surgery patients with an elevated pulmonary pressure during preoperative right heart catheterization with those obtained intraoperatively and postoperatively by means of a PAC. All patients with a preoperatively documented pulmonary artery pressure of 40 mmHg or above and an intraoperative use of a PAC during a 4-year period were included. Exclusion criteria were intracardiac shunts, cardiogenic shock, emergency procedures, pulmonary hypertension of non-cardiac origin and a time span of more than 1 year between right heart catheterization and surgery. We included 90 patients.

Results

In the whole group and in the subgroups (according to diagnosis, time elapsed between heart catheterization and operation and pulmonary pressure), there were significant differences between preoperative and intraoperative pulmonary and systemic pressures. Systemic and pulmonary artery pressures were significantly higher during preoperative catheterization than intraoperatively. The systemic systolic pressure/systolic pulmonary pressure ratio, however, remained constant. The intraoperative and postoperative systemic and pulmonary artery pressures showed no significant differences. As a normal ejection fraction does not exclude heart failure with preserved ejection fraction and as we did not have any information on this condition, we did not group the patients according to the ejection fraction.

Conclusion

An elevated pulmonary pressure obtained preoperatively during right heart catheterization is not indicative of an elevated pulmonary pressure either intraoperatively or postoperatively. There are various explanations for the differences (e.g., different physiological and pathophysiological settings, such as sedation with potential hypercapnia versus anesthesia with vasodilation when measured; newly prescribed medication coming into effect between the right heart catheterization and surgery; intraoperative positioning). Even though the inherent risks of a PAC seem to be low, we recommend refraining from using a PAC in patients with a once documented elevated pulmonary pressure by default. As an alternative we suggest estimating the pulmonary pressure by transesophageal echocardiography (TEE) as an aid to decide whether the patient will benefit from the use of a PAC. Especially if it is not possible to identify tricuspid valve regurgitation for determining the peak gradient, it is helpful to check for additional signs of pulmonary hypertension. But we also have to bear in mind that in the postoperative period only a PAC can provide continuous measurement of pulmonary pressure.

     

Neuromuskuläre Restblockade

Even small degrees of residual neuromuscular blockade, i.?e. a train-of-four (TOF) ratio >0.6, may lead to clinically relevant consequences for the patient. Especially upper airway integrity and the ability to swallow may still be markedly impaired. Moreover, increasing evidence suggests that residual neuromuscular blockade may affect postoperative outcome of patients. The incidence of these small degrees of residual blockade is relatively high and may persist for more than 90?min after a single intubating dose of an intermediately acting neuromuscular blocking agent, such as rocuronium and atracurium. Both neuromuscular monitoring and pharmacological reversal are key elements for the prevention of postoperative residual blockade.     

Digitale Vernetzung in der Medizin

Being efficiently connected is a prerequisite of good emergency trauma care. Primarily, a good interplay among all experts involved in healthcare and their respective disciplines leads to the best outcome in emergency trauma care and helps in the prevention of such emergencies. Additionally, the connectedness of the healthcare process as a matter of principle serves the purpose of occupational accident insurance institutions and can be considered to be causally contributing to its success. The advent of digital technologies can only further optimize such connectedness. This is reason enough to closely follow the applications of digital medicine and to exploit the possibilities for further development and advancement of emergency trauma care.