Anästhesie und Analgesie in der Stillperiode

There is no sound information concerning the safe and correct use of analgesics and anesthetics during the lactation period based on studies with a large sample size. Available information is limited to case studies and small sample observations. As a result, information given by the drug manufacturers about the use of drugs during the lactation period is often restrictive or contains contraindications for the lactation period. Although some drugs are not officially licensed for use during lactation they need to be administered in daily (off-label) use. This review gives an overview about the recent knowledge and clinical experience concerning the perioperative use of anesthetics and analgesics during breast feeding.     

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.     

Anästhesie in der Geburtshilfe

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

Anästhesie in der Augenheilkunde

Narkosen in der Augenheilkunde bieten zahlreiche Besonderheiten. Die Patienten geh?ren aufgrund ihres Alters und/oder ihrer Begleiterkrankungen h?ufig zu den ASA-Risikogruppen III und IV. Operative Manipulationen am Auge und die eingesetzten Ophthalmika k?nnen gravierende systemische Effekte v.a. im Bereich des kardiovaskul?ren Systems aufweisen. Umgekehrt beeinflussen zahlreiche an?sthesiologische Ma?nahmen und Pharmaka den intraokularen Druck, dessen unkontrollierter Anstieg zum Visusverlust führen kann, wenn eine Netzhautisch?mie auftritt oder intraokul?re Strukturen aus operativ angelegten oder traumatischen Perforationsstellen herausgepresst werden. Am Auge wird eine Vielzahl verschiedener operativer Verfahren durchgeführt, die sich grob in extraokul?re und intraokul?re Eingriffe unterteilen lassen. W?hrend bei den intraokul?ren Eingriffen aufgrund der Er?ffnung des Auges die Kontrolle des Augeninnendrucks und die Akinesie des Bulbus von entscheidender Bedeutung sind, steht bei extraokul?ren Eingriffen die Vermeidung bzw. die Therapie des okulokardialen Reflexes im Vordergrund. Durch Kenntnis der Anatomie, (Patho-)Physiologie und Pharmakologie des Auges kann der An?sthesist wesentlich zum Gelingen der operativen Verfahren beitragen.

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Sachkostenerfassung in der Anästhesie

Background and goal

For reimbursement via diagnosis-related groups (DRG), lump compensation-based payment of medical cases in German hospitals requires a case-related measuring and billing of resources that has to be consistent with DRG guidelines. Only through this, can the real costs be compared with the standard costs as calculated by the hospital reimbursment system (InEK) on a case-related basis and the DRG-specific break-even level be identified.

Methods

In the present paper the authors introduce and validate two newly created alternative methods for case-related allocation of material costs in the field of anaesthesia. Method 1 allows online documentation of material costs via pre-defined anaesthesia standards. This full cost method is suitable for hospitals that have implemented an electronic hospital information system in their daily clinical documentation routine. For other hospitals method 2 could be applicable as the case-related allocation of material costs is done retrospectively based on the data collected in an electronic anaesthesia protocol record system (andoc, medlinq).

Results

Method 1 makes it possible to allocate 90.3% of anaesthesia-related material costs to a specific case corresponding to a Pearsson coefficient of 0.77. After iterative improvement through optimisation of modules the documentation quality could be raised to >98% and a Pearsson coefficient of 0.96. Although the expense for implementation and maintenance is considerable, the necessary documentation work for the clinician is low. Method 2 demands no further clinical effort in documentation and implementation and 49.1% of all material costs can be assigned on a case-related basis.

Conclusions

The online documentation of material costs via predefined anaesthesia standards accounts for nearly all material costs in anaesthesia and only a negligible documentation effort is necessary for the clinician. Nevertheless, a complex and time-consuming configuration of standards and a continuous iterative alignment of the modules with the actual processes are required. Due to its process-orientated character, method 1 can also be usedfor workflow optimisation in terms of standard operating procedures (SOPs). Allocation of material costs with data from the electronic anaesthesia record system is a method that can be easily implemented but only a partial case relation is rendered possible.     

Personalbedarfskalkulation in der Anästhesie

Historically, calculation of staffing requirements for anesthesia has developed from index numbers derived from the workplace method to the service performance method (XX time). The DRG revenues result from an average calculation of costs that results from an assumed calculation of staffing requirements based on the service performance method. In contrast to the principle of full cost coverage, a much stronger process orientation is needed under the conditions of the DRG system. When calculating personnel needs this process orientation also requires that it be oriented to the organization by differentiating between theater-related and non-theater-related anesthesiological services. In a second step the services rendered in a specified organization are then assessed for efficiency and if necessary optimized. Just as it applies to the whole clinical center, in departments of anesthesiology DRG revenues should be brought in line with the actual costs.     

Anästhesie in der Thoraxchirurgie

Thoracic surgery represents a special challenge for anesthesia and requires a high level of human and material resources. Accurate knowledge of the pathophysiology is essential for selection of the anesthetic procedure, the separation of the lungs, monitoring and treatment of hemodynamics as well as for postoperative follow-up care. The increasing number of thoracic interventions and patients who are often suffering from complex diseases require close interdisciplinary cooperation between surgeons, anesthesiologists and intensive care specialists. In addition to the anesthetic techniques particular attention must be paid to the prevention of perioperative complications that can have a relevant effect on patient outcome. In particular hypoxemia during one-lung ventilation influences postoperative morbidity and mortality. Protective pulmonary ventilation strategies play an important role in prevention of postoperative acute lung injury.     

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.     

Moderne Anästhesie in der Bauchchirurgie

Zusammenfassung Keine einzige Betäubungstechnik ist bei allen Bauchoperationen anwendbar. Jeder Fall muß im Lichte von des Patienten Zustand und der chirurgischen Prozedur, der er unterworfen werden soll, betrachtet werden. Stoffwechselfehler sollten vor der Operation so weit wie möglich berichtigt werden, und wo die Blutmenge eines Kranken verringert ist, sollte sie wieder normalisiert werden. Ätheranästhesie wird wohl zufriedenstellend sein bei Eingriffen, die weniger als 1 Stunde dauern und an gesunden Menschen ausgeführt werden. Wo längere und tiefe Muskelentspannung notwendig ist, wird die Spinalanästhesie besser sein, vorausgesetzt, daß der Patient eine ausreichende Zirkulationsstabilität hat, um die folgende vasomotorische Störung auszuhalten. Das indianische Pfeilgift bringt eine Muskelentspannung, welche der durch die Spinalanästhesie erzielten etwa gleichkommt, und zwar ohne jede störende Wirkung auf das Herz- und Gefäßsystem, Leber oder Nieren, obgleich die Atmung oft tief herabgedrückt wird. Das Pfeilgift muß mit einer leichten Allgemeinbetäubung kombiniert werden, aber da nur die tieferen Ebenen der Wirkung von Betäubungsmitteln gefährlich sind, findet dieses Gift eine breite Verwendung, besonders bei Patienten, die Spinal- oder Ätherbetäubung nicht überstehen würden. In wirklich schlechten Fällen bleibt jedoch die Verwendung der Lokalinfiltration und der regionalen Blockadeanästhesie die Zuflucht des Narkosearztes. Diese Methoden sind nicht mehr wie früher eine Qual. Jetzt ist es möglich, ihre unvermeidbaren Mängel mit hilfe von Pentothal auszugleichen und diese besondere Narkoseform vom Standpunkt des Patienten zur angenehmsten von allen zu machen.Mit 4 Textabbildungen.Übersetzung ins Deutsche von Frl. Dr.Oda v. Gal (Univ. Heidelberg).     

Klug entscheiden in der Anästhesie

Die Anaesthesiologie -     

Das Long-QT-Syndrom in der Anästhesie

The long QT syndrome (LQTS) is a rare, congenital or acquired disease, which may lead to fatal cardiac arrhythmias (torsade de pointes, TdP). In all LQTS subtypes, TdPs are caused by disturbances in cardiac ion channels. Diagnosis is made using clinical, anamnestic and electrocardiographic data. Triggers of TdPs are numerous and should be avoided perioperatively. Sufficient sedation and preoperative correction of electrolyte imbalances are essential. Volatile anaesthetics and antagonists of muscle relaxants should be avoided and high doses of local anaesthetics are not recommended to date. Propofol is safe for anaesthesia induction and maintenance. The acute therapy of TdPs with cardiovascular depression should be performed in accordance with the guidelines for advanced cardiac life support and includes cardioversion/defibrillation and magnesium. Torsades de pointes may be associated with bradycardia or tachycardia resulting in specific therapeutic and prophylactic measures.     

Geschichte der Anästhesie

In the western World 16 October 1846 is often called “Ether Day”, marking the beginning of anesthesia. Before that date, for physicians there was only a struggle against pain. In the following 170 years all fields of general anesthesia as well as regional and local anesthesia were continuously developed. Pharmacological developments and technical innovations made this evolution possible. The complexity of this field of medicine requires a specialist: the anesthesiologist, whose selection of the most suitable form of anesthesia for the patient makes the surgical intervention painless. In addition, the history of anesthesia was characterized by personalities who were responsible for the progress of this medical field. Anesthesia is one part of the discipline of anesthesiology, which also includes resuscitation, intensive care medicine, emergency medicine and pain therapy.     

Latexallergie Perioperatives Management in der Anästhesie und Kardioanästhesie

The frequency of perioperative allergic responses to latex has markedly increased over the last 10 years. High risk groups to develop sensitivity to latex include healthcare workers, workers in the latex industry, children suffering from congenital malformations such as spina bifida or urogenital deformities and patients who have undergone multiple surgical procedures. During surgery, patients have contact to a variety of products containing latex. To prevent anaphylactic reactions, all hospitals have to develop strategies to identify and manage patients sensitised to latex or belonging to high risk groups. The aim of this paper is to describe safe perioperative management in a latex-free environment.     

Lehrmethoden in der Anästhesie und Intensivmedizin

ZusammenfassungHintergrund Die neue, am 01.10.2003 in Kraft getretene ärztliche Approbationsordnung (AO) hat weitreichende Veränderungen der Studienstruktur und der Anforderung an Lehrende zur Folge, die den die Studienordnungen der einzelnen Fakultäten umgesetzt werden müssen.Material und Methoden Mit der Einführung eines praxisorientierten, interdisziplinären Kurscurriculums wurden die Voraussetzungen für die Erfüllung der neuen AO etabliert. Ein Modell aus traditionellen Vorlesungen, Seminaren, Praktika und Falltutorien im Sinne der problemorientierten Wissensvermittlung (Dresdener integratives praxisorientiertes Lernen, DIPOL^®) ist für das gesamte vorklinische und klinische Studium implementiert worden.Ergebnisse Beispielhaft werden die Evaluationsergebnisse des Kurses Notfallmedizin—Verletzungen—Intensivmedizin (NVI) des Jahres 2003 dargestellt. Insgesamt zeigt sich eine hohe Zufriedenheit der Studierenden und Tutoren mit einer Bestehensquote von 95%.Schlussfolgerung Der NVI-Kurs erfüllt die Voraussetzung für die Scheinvergabe im Fach Anästhesiologie nach der neuen AO. Regelmäßige strukturierte Evaluation von Lehrinhalten und -methoden sowie Berücksichtigung der Evaluationsergebnisse sind Bestandteile für die Kontrolle der Ausbildungsqualität und die weitere Entwicklung eines Reformcurriculums.     

Qualitätssicherung Hämotherapie in der Anästhesie

BACKGROUND: The measures for quality assurance in haemotherapy developed at the Charite Campus Mitte according to the transfusion law of 1998 are introduced and discussed. METHODS: In a 3-year study period the submission of transfusion documentation and the expiration of blood products were compared to the year 2001. The potentials for improvement for 2001-2003 were compared based on evaluation of the self-inspection documentation of the transfusion clinics. RESULTS: The submission rate for the transfusion documentation increased from 90% in 2001 to 98.3% in 2002 and 2003. The expiration of blood products decreased from 5.1% in 2001 to 1.7% in 2003 resulting in a cost reduction from 140,000 Euro to 50,000 Euro. Continuous need for improvement was found for the prescribed annual further education of staff on quality management. CONCLUSIONS: The self-inspection procedure in transfusion clinics still revealed potential for improvement, although documentation of transfusions were improved and the expiration of blood products and the resulting costs were substantially reduced.     

Stellenwert der Anästhesie in multimodalen onkologischen Therapiekonzepten

Patients with malignant diseases are increasingly being treated with multimodal therapeutical concepts based on the three major modalities surgery, radiotherapy and chemotherapy. The perioperative period is crucial within this multimodal concept as the prognosis of patients may be directly influenced by perioperative measures. In addition, it is of major importance to avoid complications in the perioperative phase, as these might worsen the prognosis of the patient and in order to prevent a delay in the beginning of planned adjuvant therapies. These aspects demonstrate the important role of anesthesia in the treatment of patients with cancer. Further studies defining the relevance of anesthesiologic measures in oncologic patients are needed.     

Negative und positive Suggestionen in der Anästhesie

In extreme situations, for example during emergencies or when facing surgery, patients exhibit heightened and focused attention and increased susceptibility to suggestion. In this trance-like state negative suggestion, usually spoken unintentionally can aggravate anxiety, stress and pain. On the other hand words can offer an opportunity to benefit the patient via positive suggestion. In order to improve communication with anxious patients during stressful and painful medical procedures, certain hypnotherapeutic insights and methods can be employed, such as utilization, reframing, indirect suggestion, safe place, dissociation, metaphors, posthypnotic instructions and non-verbal communication and this without requiring formal hypnotic induction and without need for additional time, premises or personnel. Indications for such approaches are the preoperative visit, induction of anaesthesia, as well as operations under local or regional anaesthesia. An extreme example of the latter is awake craniotomy employing cranial nerve blocks and an awake-awake technique avoiding centrally acting drugs. Such hypnotic communication can help the patient to regain self-control and access to inner resources.