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.     

Levobupivacain in der Regionalanästhesie

Zusammenfassung Levobupivacain [S(-)Bupivacain] ist heute in den meisten Ländern der EU sowie in den USA zugelassen und erhältlich. In einer systematischen Literaturrecherche in der Datenbank MEDLINE wurden 88 klinische Studien identifiziert, in denen insgesamt 3265 Patienten den Gruppen mit Levobupivacain zugeteilt waren. Die klinische Anwendung von Levobupivacain ist für alle wesentlichen Verfahren der Regionalanästhesie und für alle gängigen Indikationen, teilweise kombiniert mit Adjuvanzien, beschrieben. Levobupivacain kann somit epidural (einschließlich kaudal), spinal, bei peripheren Nervenblockaden (einschließlich Plexusblockaden), bei der Paravertebralblockade, bei peribulbären Blockaden, beim Penisblock, in der i.v.-Regionalanästhesie, in der Infiltrationsanästhesie und in der Zahn-Mund-Kiefer- (ZMK-)Anästhesie für die in den Tabellen genannten Indikationen eingesetzt werden. Als kombinierbare Adjuvanzien können epidural Fentanyl, Morphin, Sufentanil, Adrenalin und Clonidin angewendet werden, bei der Spinalanästhesie Sufentanil, Fentanyl und Adrenalin. Als Vergleichssubstanzen wurde in den vorliegenden Studien meist Bupivacain und/oder Ropivacain herangezogen.     

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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Nalbuphin in der Kinderanästhesie

Efficient and safe pediatric perioperative pain therapy in the context of a multimodal pain therapy concept requires a slight to moderate opioid analgesic. Nalbuphine is a nearly ideal opioid for this purpose due to its unique pharmacological properties as a μ-receptor antagonist/κ-receptor agonist and a high safety profile. Nalbuphine is used clinically primarily in postoperative pain therapy administered as a bolus, continuous infusion and patient-controlled analgesia. Furthermore, it is administered in different regimens for pediatric diagnostic and interventional sedation.     

Anästhesie in der Stillperiode

Zusammenfassung Bei Regional- wie auch Allgemeinanästhesien während der Stillperiode stehen das Stillbedürfnis der Mutter und die positiven Aspekte des Stillens für Mutter und Kind den potenziell schädigenden pharmakologischen Auswirkungen auf den Säugling und auf die Laktation gegenüber. Obwohl die Kenntnis über die Exkretion von Medikamenten in die Muttermilch in den letzten Jahren erheblich zugenommen hat, sind die Informationen über die meisten anästhesierelevanten Medikamente weiterhin lückenhaft und widersprüchlich. Oft ist nicht mit ausreichender Sicherheit zu entscheiden, ob eine bestimmte Substanz, die potenziell über die Muttermilch zum Säugling übertritt, für das gestillte Neugeborene unschädlich ist. Zudem besitzen die wenigsten Anästhetika und Adjuvanzien eine explizite Zulassung während Schwangerschaft und Stillperiode, und die meisten Hersteller raten aus haftungsrechtlichen Gründen generell von der Anwendung nahezu aller Medikamente während Schwangerschaft und Stillzeit ab. In Kenntnis des pharmakologischen Profils der klinisch gebräuchlichen Allgemein- und Lokalanästhetika ist jedoch zu vermuten, dass bei einmaliger Applikation dieser Substanzen im Rahmen einer Anästhesie während der Stillperiode das weitere Stillen in der unmittelbar postoperativen Periode in den meisten Fällen als unkritisch hinsichtlich unerwünschter pharmakologischer Nebenwirkungen auf den Säugling bewertet werden kann. So ist bei sorgfältiger Auswahl der Anästhetika eine Allgemein- oder Regionalanästhesie keine Indikation zum Abstillen, und selbst elektive operative Eingriffe in Narkose während der Stillperiode müssen nicht zwingend aufgeschoben werden. Nach einem operativen Eingriff in Allgemein- wie auch Regionalanästhesie während der Stillzeit ist nach aktueller Auffassung kein wissenschaftlich begründbares Zeitintervall zwischen Anästhesie und Stillen einzuhalten, sondern die Mutter kann ihr Neugeborenes dann wieder stillen, sobald sie sich physisch und psychisch dazu wieder in der Lage fühlt.Ein Erratum zu diesem Beitrag können Sie unter finden.     

Spinalanästhesie in der Tageschirurgie

BACKGROUND: Since prilocaine is being increasingly used for day case surgery as a short acting local anaesthetic for spinal anaesthesia and because of its low risk for transient neurological symptoms, we compared it to bupivacaine. PATIENTS AND METHODS: Patients (n=88) who were scheduled for lower limb surgery with spinal anaesthesia randomly received 15 mg hyperbaric bupivacaine 0.5% or 60 mg hyperbaric prilocaine 2% (administered in a sitting position). Onset time, intensity, duration of the sensomotoric block, vital parameters and time of spontaneous miction were recorded and patients were questioned on satisfaction with the anaesthesia procedure and the occurrence of adverse side-effects after 24 h. RESULTS: Bupivacaine caused a significantly higher sensory block than prilocaine (T6 vs. T8). Both groups were similar in reaching an analgesic level of at least T12, block intensity and onset times. Median analgesic levels at T12 were maintained for 60 min with prilocaine versus 120 min with bupivacaine, regression of the motor block was 135 min versus 210 min, sensory block S1 was 240 min versus 360 min, and time for spontaneous miction was 306 min versus 405 min, respectively (differences for all comparisons were statistically significant). CONCLUSION: Under the present study conditions, hyperbaric prilocaine 2% was superior to hyperbaric bupivacaine 0.5% due to a shorter effect profile but otherwise equivalent quality of block. However, puncture in a sitting position and positioning with elevated torso for restriction of the cranial expansion of block spread might cause an enhanced sacral block with delayed recovery of bladder function.     

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.     

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.     

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.     

Regionalanästhesie in der Orthopädie

Regional anesthesia has its place in the perioperative pain management of orthopedic patients. A reduction in postoperative mortality and morbidity with regional anesthesia is acknowledged for subsets of patient populations. Single shot and continuous applications are techniques for providing regional analgesia. Continuous infusion of local anesthetics with catheter techniques provides for uninterrupted postoperative analgesia. The combination of regional and general anesthesia reduces the consumption of systemic anesthetics. The side effects of opioid therapy are thereby reduced. The inhibition of intraoperative stress reaction, especially with epidural anesthesia, helps to prevent or lower unwanted metabolic changes. Patient contentment with analgesic quality differs with the technique with which the regional anesthesia is applied (PDA, PCEA, IVRA, peripheral block, i.a. injection), and the medication (LA, opioid) used.     

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.     

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).     

Vaskulärer Zugang in der Kindernotfallanästhesie

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.