Tranexamsäure: der Stellenwert des korrekten Einsatzes und einer individualisierten Risiko-Nutzen-Abwägung

Die Anaesthesiologie -     

Auswirkung von Aprotinin und Tranexamsäure auf die Fibrinolyse und Thrombinbildung bei extrakorporaler Zirkulation

Objective: Antifibrinolytic drug therapy has proved to be effective in reducing blood loss associated with cardiac surgery and cardiopulmonary bypass (CPB). Concerns remain regarding the risk of enhancing thrombosis. In the present study we investigated the effect of aprotinin (AP) and tranexamic acid (TA) on fibrinolysis and thrombin generation during CPB. Methods: 60 patients undergoing coronary artery bypass graft surgery were randomised in 3 groups. They received either aprotinin (“high-dose-scheme”), tranexamic acid (2 g/h) or no antifibrinolytic therapy (control group). Collection of blood was performed at 7 pre-, intra- and postoperatively predetermined intervals. Fibrinolytic activity was determined by measuring concentrations of D-dimer, thrombin generation by the measurement of thrombin-antithrombin III complex (TAT). Results: There was no significant increase of D-dimers in the AP or TA group. D-dimer concentration in the control group increased significantly after starting CPB. Comparing with the control group, thrombin generation in the AP group was significant less, while TA group produced significantly higher values. Conclusion: After the administration of AP for cardiac surgery we observed reductions in both intraoperative fibrinolysis and thrombin generation. In case of TA suppression of fibrinolytic activity in the absence of concomitant reduction in thrombin generation occurred. These results suggest that TA could potentiate a hypercoagulable state with the risk of thrombosis in the perioperative setting.     

Simulationstraining zwischen „human factors“ und „technical skills“

Background

Complexity in clinical medicine has induced a higher consciousness for patient safety and clinical risk management. Technical progress has enabled transposition of learning progress towards a low-risk simulation-based environment. This has changed the former strategy in acquiring clinical abilities away from “see one, do one, teach one”.

Objective

Hereby, mobile full-scale simulators are able not only to provide an opportunity in training technical clinical skills but more often display whole chains of medical care, complex scenarios and clinical team trainings. Due to the technical advances, there is a shift in simulation-based trainings from technical to non-technical skills. Especially in the area of simulator-based team training, there is a broad heterogeneity, causing difficulties to acquire scientific evidence for their effectiveness.

Future

Essential for the establishment and the sustainable effect of simulator-based training is routine obligatory clinical training, participation of scientific associations, and integration into a clinical risk management system. Predefinition of learning targets and the selective, outcome driven use of simulation-based training are of importance.     

Tranexamsäure zur Blutungsprophylaxe bei Trauma und orthopädischen Eingriffen – Standard oder individualisierte Anwendung?

Die Anaesthesiologie - Tranexamsäure hat einen etablierten Stellenwert in der Behandlung von Blutungen, v. a. bei Hyperfibrinolyse. Zunehmend wird TXA auch prophylaktisch bei Trauma und...     

Lokalanästhetikaintoxikation und „lipid resuscitation“

Background

Animal experimental studies and many case reports lead to the conclusion that lipid therapy is effective for the treatment of local anesthetic toxicity. The mechanism of action is still unknown but two main theories exist. The first one, the metabolism theory, focuses on a possible metabolic effect of lipids to reduce tissue acidosis and decrease carbon dioxide production during periods of myocardial ischemia. The second theory is the lipid sink theory where the lipid emulsion provides a large lipid phase in serum with the ability to extract lipophilic drugs.

Method

Selective review of the literature and homepages.

Conclusions

Lipid therapy is not only effective in the treatment of local anesthetic toxicity. Intoxication with other lipophilic drugs, e.g. (tricyclic) antidepressants, anticonvulsant drugs, lipophilic beta blockers or calcium channel blockers can also be treated with lipids. National and international societies recommend the administration of lipid emulsions for the therapy of local anesthetic intoxication. Further case reports and animal studies will focus on side effects, optimal dosage and effectiveness in the treatment of intoxication with other drugs.     

„Patient reported outcome measurements“ in Orthopädie und Unfallchirurgie

Die Unfallchirurgie - Der routinemäßige Einsatz von ?patient reported outcome measurements“ (PROMs) kann die Ausrichtung des Gesundheitssystems an Wert und Nutzen für...     

Neu: Sonderheft „Facharzt-Training Anästhesiologie“

Die Anaesthesiologie -     

„Plate-assisted segmental bone transport“ mit Verlängerungsnagel und Platte

Background

Distraction osteogenesis represents an effective procedure for treatment of bone defects from various causes (e.g. trauma, malignancy, congenital and infection). In the past the available procedures were practically exclusively external.

Principles

In the plate-assisted segmental bone transport (PABST) procedure a commercially available motorized intramedullary lengthening nail is used for segment transport. The transport segment is transported along a bone plate, which is responsible for maintaining the position of the proximal and distal main fragments.

Surgical technique

In staged sequences, a plate spanning the defect is placed. A lengthening nail is inserted in an antegrade or retrograde direction and a vascularized transport segment is created with an osteotomy. Bone transport is initiated at 1.0 mm a day. The transport segment is pulled or pushed into place, depending on the location of the bone void. In due time, a docking procedure is performed and full weight bearing is allowed. Supplementary lengthening can be initiated at docking or in a separate procedure. In smaller defects the gap is closed immediately over the plate and the bone is lengthened by the nail in the opposite end of the defect.

Conclusion

The presented method is a valuable addition to the armamentarium for treatment of bone defects. The main advantages are the avoidance of external fixation (fixation wires, Schanz screws) and the creation of physiological bone substitute. Vital soft tissues are essential for a good outcome. With appropriate management (systematic debridement, local and systemic administration of antibiotics and free soft tissue flaps), this method can be a solution to even complex reconstructive problems.

     

Versuche über borsäure und vasoformpuder als händedesinfektionsmittel

Ohne Zusammenfassung     

Retrograde Typ-A-Dissektion nach „debranching“ und endovaskulärer Stentgraft-Therapie des Aortenbogens

This article describes the hybrid repair of a large thoracic aneurysm of the transverse arch and the descending aorta in an 81-year-old patient using the debranching technique with subsequent thoracic endovascular aortic repair (TEVAR). On postoperative day 10 the patient suffered a retrograde type A aortic dissection – involving the ascending aorta and the aortic root – with acute tamponade. After stabilization the patient successfully underwent emergency supracoronary ascending aortic replacement by performing of a distal elephant trunk anastomosis.     

„Virtual reality simulation“ in der Orthopädie und Unfallchirurgie in Frankreich

Die Unfallchirurgie - Die aktuelle Verkürzung der Arbeitszeit und der Versuch, auf der ganzen Welt Sicherheit für den Patienten zu garantieren, führen zu erheblichen...     

Über bau,wachstum und ursprung der gelenkmäuse

Ohne Zusammenfassung     

Biologisch azetabuläre Defektrekonstruktion beim Hüftendoprothesenwechsel mittels „Impaction Grafting“ und azetabulärem Rekonstruktionsring

Objective

Management of acetabular bone defects Paprosky types IIa and IIb in revision hip arthroplasty by rebuilding the bone stock using impaction bone grafting, primary stable reconstruction with an acetabular reconstruction ring, and restoring the hip center of rotation to its anatomical position.

Indications

Acetabular segmental or combined structural defects in the superior acetabular dome with superior/lateral hip center migration with intact anterior and posterior columns (Paprosky types IIa, IIb).

Contraindications

Acute or chronic infections, severe acetabular bone defects preventing adequate anchorage of the prosthesis—particularly destruction of the posterior column.

Surgical technique

Modified transgluteal, lateral approach to the hip joint. Removal of the loose acetabular component. Complete circumferential exposure of the acetabular rim, while maintaining mechanical stability of the remaining bone. Preparation of the homologous spongiosa chips and reconstruction of the acetabular defect in impaction grafting technique. Implantation of the acetabular reconstruction ring and primary stable fixation with cancellous screws in the acetabular dome. Cemented fixation of a polyethylene inlay.

Postoperative management

Mobilization on 2 underarm crutches from postoperative day 1. Partial weight bearing with 20 kg for 6 weeks postoperatively. If plain radiographs show unchanged seating of the prosthesis after 6 weeks, loading can be increased by 10 kg/week until full weight bearing is achieved; thrombosis prophylaxis is continued throughout. Limitation of hip flexion to 90° during the first 6 weeks, and no adduction and forced external rotation to avoid dislocation. Avoidance of sports involving jumping and axial impact loading for 12 months. Radiologic checkups after 3, 6, and 12 months and, thereafter, every 2 years.

Results

Analysis between 2008 and 2011 involved 22 consecutive patients with a total of 23 prostheses; the mean follow-up was 38?±?11 months. Compared to the preoperative evaluation, follow-up yielded a significant improvement in the average Harris Hip Score (82.2?±?8.7 vs. 44.7?±?10.7) and the Merle d’Aubigné Score (14.6?±?1.9 vs. 7.5?±?1.3). Radiological solid osseointegration of the cup was observed in 21 cases; partial radiolucent lines were seen in 2 cases (9?%) in the zones I–III delineated by DeLee and Charnley. In 21 cases (91?%) radiographs confirmed no measurable migration or displacement of the acetabular component and the bone graft was determined to be incorporated on the basis of osseous consolidation within the grafted area in 20 cases (87?%). During follow-up 3 prosthesis (13?%) required revision.     

Postoperativer „paralytischer“ Ileus und Heidenhainsche Darmfistel

Ohne Zusammenfassung     

„Coronavirus disease 2019“ (COVID-19): update für Anästhesisten und Intensivmediziner März 2020

Die Anaesthesiologie - Die neu aufgetretene Atemwegserkrankung „coronavirus disease 2019“ (COVID-19) hat Deutschland erreicht. Die Erkrankung verläuft in den meisten Fällen...     

Zusammenhänge zwischen fibrinolytischer Aktivität des Blutes und aseptischen Wundheilungsstörungen im Tierexperiment

Zusammenfassung Es wird im Tierversuch nachgewiesen, daß es durch Steigerung der fibrinolytischen Aktivität des Blutes mit Hilfe von Streptokinasen gelingt, die Wundheilung wesentlich zu stören und die Reißfestigkeit der Muskulatur laparotomierter Ratten auf fast ein Viertel des Normalwertes herabzusetzen. Diese Wirkung ist um so klarer, je früher der Fibrinabbau in Gang gesetzt wird. Eine Verhinderung der Wundheilungsstörung durch gleichzeitige Gabe von antifibrinolytischen Stoffen konnte gezeigt werden. Auf Grund dieser Ergebnisse wird die Ätiologie des Platzbauches diskutiert und die Möglichkeit der Verhinderung derartiger unangenehmer postoperativer Komplikationen im klinischen Bereich erörtert. Eine ähnliche Nebenwirkung von Heparin auf die Wundheilung konnte bei der verwendeten Dosierung nicht beobachtet werden.Mit 4 TextabbildungenAuszugsweise vorgetragen in der wissenschaftlichen Sitzung der Gesellschaft der Chirurgen in Wien, im Mai 1962.