Die Anästhesie der Anästhesie

Viewed from a cultural-ethical perspective, anesthesiology can be understood as a comprehensive concept of medicine in general. As such it contains two dilemmas: very often pain must be inflicted in order to alleviate pain and this can only be done by somebody who is himself relatively free of pain. The necessary apathy or anesthesia of the anesthetist is correlated with a general twentieth century-type of perception: the cool observer. Nevertheless, it is also a modern variation of the original religious constellation of the priest in relationship to the sick person. Curing occurs by representation. The weak self of the sick person is able to take over the strong self, represented by the therapist. In twentieth century art and literature this process of self-therapy by representation was often illustrated. On the background of a phenomenological philosophy that process can be understood as the regaining of a balance between body and soul. In the psalms of the biblical Book of Job there a variety of fundamental forms of pain which may be helpful even in this secular age.     

Periphere Regionalanästhesie beim Patienten in Allgemeinanästhesie

Nerve injury after peripheral regional anesthesia is rare and is not usually permanent. Some authors believe that inducing peripheral nerve blocks in patients during general anesthesia or analgosedation adds an additional risk factor for neuronal damage. This is based on published case reports showing that there is a positive correlation between paresthesia experienced during regional anesthesia and subsequent nerve injury. Therefore, many sources recommend that regional nerve blocks should only be performed in awake or lightly sedated patients, at least in adults. However, there is no scientific basis for this recommendation. Furthermore, there is no proof that regional anesthesia performed in patients under general anesthesia or deep sedation bears a greater risk than in awake or lightly sedated patients. Currently anesthesiologists are free to follow personal preferences in this matter as there is no good evidence favoring one approach over the other. The risk of systemic toxicity of local anesthetic agents is not higher in patients who receive regional anesthesia under general anesthesia or deep sedation. Finally, in children and uncooperative adults the administration of peripheral nerve blocks under general anesthesia or deep sedation is widely accepted.     

Einseitige Spinalanästhesie

Unilateral spinal anesthesia is a cost-effective and rapidly performed anesthetic technique. An exclusively unilateral block only affects the sensory, motor and sympathetic functions on one side of the body and offers the advantages of a spinal block without the typical adverse side effects seen with a bilateral block. The lack of hypotension, in particular, makes unilateral spinal anesthesia suitable for patients with cardiovascular risk factors e.?g. aortic valve stenosis or coronary artery disease. Increasing numbers of surgical procedures are now being performed on an outpatient basis. Until now, spinal anesthesia has been considered unsuitable for this, not only because of the high incidence of intraoperative hypotension and postoperative urinary retention but also because of the prolonged postoperative stay before home discharge. This is not the case with unilateral spinal anesthesia: motor function returns rapidly, the incidence of urinary retention is extremely low, and patients are usually eligible for home discharge sooner than after bilateral spinal anesthesia or general anesthesia. The success of the technique depends on a number of factors. In addition to the local anesthetic, its concentration and dose, and the baricity of the injected solution, the shape of the spinal needle, the injection speed, the patient’s position during injection, and the time the patient remains in this position after injection are equally important parameters. A number of intrathecally applied adjuvant drugs are used to give a more intense and/or longer-lasting block. For this review, we collated the published data on unilateral spinal anesthesia from journals with an impact factor greater than 1.0 and defined an optimized method for performing the technique. In order to achieve an exclusively unilateral block one should use 0.5?% hyperbaric bupivacaine injected at a rate of 0.33 ml/min or slower. During the injection and the following 20 min the patient should lie in the lateral decubitus position on the side intended for surgery with knees drawn to the chest. An injection of 5 mg (1 ml) hyperbaric bupivacaine 0.5?% provides an hour-long block to T 12, and a dose of 7.5 to 10 mg (1.5–2.0 ml) extends the block to T 6. Adding clonidine (0.5 to 1.0 µg/kg BW) to the injection prolongs the duration of the block to approximately two to three hours. During the 20-minute fixation period, the cephalad spread of the block can be influenced to a certain extent by raising or lowering the head of the table.     

Patientenorientierte Anästhesie

Goals of this study were to quantify patients' preferences for anaesthesia care and to identify what they know about various tasks of an anaesthetist. On the day before surgery, 122 patients scheduled for elective procedures were interviewed using a structured questionnaire. A reliable pain relieve and unawareness as well as stable vital functions have priority in patients' preferences. Patients are also concerned with good postoperative pain relieve and the avoidance of nausea and vomiting. Not important are short preoperative soberness, rapid awakening and initial wide awakeness. Not informed about typical tasks of an anaesthetist are 28-51% of the patients. In order to obtain maximum patient satisfaction, a thorough education plus further continuous training are the essential items for a patient orientated health care management in anaesthesia, along with good medical and technical equipment. The wide spectrum of tasks of an anaesthetist must be better represented in order to strengthen the position of anaesthesia in the competition for rare resources. A postoperative visit, which is judged of 77% of the patients as important, offers a beginning.     

Thorakale Epiduralanästhesie

Ohne Zusammenfassung     

Anästhesie zur Karotischirurgie

Carotid endarterectomy (CEA) has remained the first choice of treatment in preventing ischemic stroke due to symptomatic stenosis of the internal carotid artery despite other new available options. During CEA patients are first and foremost at risk of cerebral as well as myocardial ischemia, therefore, maintenance of the oxygen supply to the brain and the myocardium is of outstanding importance requiring reliable monitoring of cerebral and cardiac function. The regional versus general anesthesia debate is an age-old one that has brought few definite answers regarding the impact on postoperative outcome of either anesthetic technique. Up to now, there is little evidence from only a few randomized clinical trials to demonstrate the superiority of either anesthetic technique with respect to outcome parameters. Because the level of evidence in favor of regional anesthesia during CEA can at least be rated between 1(-) and 2(+) the resulting recommendation is grade C. The purpose of the review is to highlight the characteristics and goals of anesthetic management during CEA.     

Thrombozytenaggregationshemmer bei Spinalanästhesie

Ohne Zusammenfassung     

Anästhesie und Schlaf-Apnoe-Syndrom

The perioperative risk for patients with obstructive sleep apnea syndrome and the optimal anaesthesiological management of these patients have not been well elucidated. The prevalence of obstructive sleep apnea with significant symptoms is estimated to be 4% in men and 2% in women. However, in 80-95% of patients this syndrome is not sufficiently diagnosed. Thus identification of patients at risk and a thorough multidisciplinary diagnostic approach are essential for optimal perioperative management. The risk of perioperative complications, like cardiopulmonary compromise, and difficulties in airway management is elevated. The most important aspects of perioperative management include evaluation of intubating conditions, careful search for cardiopulmonary morbidity, permanent control of patient airways, sensible use of anaesthetics, sedatives, and narcotics, and strict monitoring of vital signs. If ambulatory nasal continuous positive airway pressure (CPAP) therapy has been established preoperatively, this should be continued in the perioperative period. Postoperative monitoring should be performed in an intensive care or intermediate care unit. Controlled clinical studies on the best perioperative management of patients with obstructive sleep apnea are urgently required.     

Aids und Anästhesie

17 years after the discovery of HIV Aids remains an ultimately fatal disease. Currently no vaccine is available. The worldwide incidence of HIV-infections and Aids associated mortality are rising. Only in Western Europe and in the USA are incidence and mortality of Aids declining; mainly as a result of effective antiretroviral therapy. 20% to 25% of HIV-infected patients require surgery during their illness. The challenges for the anaesthesiologist are possible dysfunction of all important organs and adverse interactions between antiretroviral drugs and anaesthetic agents. If adequate infection control measures are taken the risk of occupational HIV-infection is low, but remains a concern in light of the consequences. Seroconversion after needlestick injury is ca. 0.3%, after contact with mucosa ca. 0.03%.     

Karotisoperation in Lokoregionalanästhesie

Purpose.

Carotid artery surgery, when performed under local anesthesia, allows continuous neurologic monitoring of the patient during the procedure. The surgeon is in permanent contact with his patient and can clearly decide on the necessity of intraluminal shunt placement.

Methods and results.

From October 1992 to December 2001, 2014 carotid artery operations were performed, of which 1912 were under local anesthesia. All adverse reactions due to the local anesthetic were recorded in a separate datasheet. Three cases of bradycardia, two cases of cardiac arrest, and three epileptic episodes were observed.

Conclusion.

Patients benefit from a risk reduction due to local anesthesia and hence from short hospital stays. Furthermore, neuromonitoring of the patient during local anesthesia allows a much more selective shunt policy. Reduced overall costs are another favorable side effect of the technique.     

Anästhesie im Internet

Eine unüberschaubare Anzahl medizinischer Institutionen stellt ihre Informationen im Internet zur Verfügung. Die gezielte Suche ist jedoch oft erschwert durch das riesige und unstrukturiert vorliegende Angebot. In speziellen – of E-Mail (Elektronischer Post) basierenden – Diskussionsgruppen k?nnen sich jedoch Mediziner über allt?gliche Fragestellungen und Probleme miteinander austauschen, Kontakte knüpfen und Experten befragen. Nach dem Vorbild amerikanischer "Discussion Groups" zur An?sthesie wurde von den Autoren 1996 das erste deutschsprachige An?sthesie-Diskussionsforum "HYPNOS" ins Leben gerufen, das nun allen Kollegen aus den Bereichen An?sthesie und Intensivmedizin kostenlos zur Verfügung steht. Vielleicht wird auch hierzulande die Nutzung des Kommunikationsmediums Internet bald zu einer Selbstverst?ndlichkeit im klinischen Alltag, der Forschung und Lehre werden.     

Tinnitus nach Anästhesie

Possible connections between different forms of anaesthesia and the occurrence of tinnitus or increasing levels of tinnitus are described. After general anaesthesia no increase in the occurrence or level of tinnitus is to be expected, but there exists a very rare, but specific form of low frequency tinnitus combined with low frequency sensory hearing loss following spinal anaesthesia. Reversible tinnitus and hearing disorders following local anaesthesia normally occur in cases of central nervous system toxicity.     

Sedation durch Spinalanästhesie

A sedative effect of spinal anaesthesia has been described but has attracted little attention in clinical practice. The present study was designed to assess the mood state of unpremedicated surgical patients under spinal anaesthesia with a quantitative self-rating method. Methods: 15 unpremedicated patients scheduled for minor operations under spinal anaesthesia were enrolled in this study. After administration of 25?mg ephedrine s.c. for stabilization of blood pressure spinal anaesthesia was induced with 20?mg hyperbaric 0.5% bupivacaine. The mood state was assessed immediately before and 20?min after induction of spinal anaesthesia with the adjective checklist (ACL) of Janke and Debus. The ACL is a method of self-assessment by acceptance or refusal of 123 adjectives. Results: No significant changes in heart rate and blood pressure occured during the observation period. The main changes in mood state consisted in a increase in ’’desactivation’’ and ’’fatigue’’ and in a decrease in ’’activation’’, ’’excitement’’ and in ’’anxiety’’. Discussion: In unpremedicated subjects the effect of spinal anaesthesia on mood state manifests itself mainly in sedation. This effect is most likely due to the deafferentiation with pronounced reduction of muscle afferent activity. It seems reasonable to refrain from a sedative premedication in many patients scheduled for spinal anaesthesia. If sedative drugs are given, an interaction with the non-pharmacological sedation of the deafferentiation must be taken into account.     

Schäden in der Anästhesie

The Schlichtungsstelle in Hannover (expert panel for arbitration), northern Germany, was founded in 1976 to settle disputes between patients and doctors. Furthermore, publications regarding the decisions of the Schlichtungsstelle serve as an important medium to prevent malpractice by increasing doctors' awareness of critical processes in their field. Between 2001 and 2005 the Schlichtungsstelle decided on 435 malpractice claims in anaesthesia. An accumulation of injuries was observed in anaesthetic procedures with respect to the airways (23.9%), injuries related to regional anaesthesia (18.2%), vasopuncture (13.1%) and positioning of the patients (9.9%). In 21.8%, the Schlichtungsstelle advised to seek a resolution without going to court by paying financial compensation in favour of the patient. In these cases the Schlichtungsstelle's evaluation had come to the conclusion that malpractice was the cause of the patient's injury. We would like to mention that 21 cases of intraoperative awareness were included in the claims, of which 52.4% (average 21.8%) were evaluated to be the result of malpractice and thus financial compensation was advised. The appropriate care for the patient, required from every doctor, calls the anaesthesiologists to avoid all possible malpractices, thus reducing patients' injury due to such malpractices to a minimum. But even injuries not caused by malpractice need to be examined closely and improvement should be sought.     

Qualitätsmanagement in der Anästhesie

Quality of care and costs are getting closer together. Whereas costs and quality management did not play a substantial role 30 years ago, the consumption of resources nowadays is part of the outcome of quality of care. The definition of quality must be seen in the dimensions of structure, process and result. Resulting from newly developed clinical practice, guidelines are planned as instruments for cost containment in near future. Those guidelines may end up in a quality management system. The most wellknown european basic of such a quality management system are the DIN EN ISO 9000 f and the EFQM. The ISO 9001 and the European Quality Award became the most common base of evaluation for certification of quality management systems in Organisations European wide. Whereas the ISO 9001 does not give any information about the real achieved quality, the European Quality Award reflects the process.Guidelines are necessary to prove the cost effectiveness of measures of quality control and quality assurance since too much quality control and assurance may result in increased overall consumption of resources, leading to a reduction in the quality of care when ensuring that the overall budget is covered.