Pharmakogenetik in Anästhesie und Intensivmedizin

Pharmacotherapy is a key component of anesthesiology and intensive care medicine. The individual genetic profile influences not only the effect of pharmaceuticals but can also completely alter the mode of action. New technologies for genetic screening (e.g. next generation sequencing) and increasing knowledge of molecular pathways foster the disclosure of pharmacogenetic syndromes, which are classified as rare diseases. Taking into account the high genetic variability in humans and over 8000 known rare diseases, up to 20?% of the population may be affected. In summary, rare diseases are not rare. Most pharmacogenetic syndromes lead to a weakening or loss of pharmacological action. In contrast, malignant hyperthermia (MH), which is the most relevant pharmacogenetic syndrome for anesthesia, is characterized by a pharmacologically induced overactivation of calcium metabolism in skeletal muscle. Volatile anesthetic agents and succinylcholine trigger life-threatening hypermetabolic crises. Emergency treatment is based on inhibition of the calcium release channel of the sarcoplasmic reticulum by dantrolene. After an adverse pharmacological event patients must be informed and a clarification consultation must be carried out during which the hereditory character of MH is explained. The patient should be referred to a specialist MH center where a predisposition can be diagnosed by the functional in vitro contracture test from a muscle biopsy. Additional molecular genetic investigations can yield mutations in the genes for calcium-regulating proteins in skeletal muscle, e.g. ryanodine receptor 1 (RyR1) and calcium voltage-gated channel subunit alpha 1S (CACNA1S). Currently, an association to MH has only been shown for 35 mutations out of more than 400 known and probably hundreds of unknown genetic variations. Furthermore, MH predisposition is not excluded by negative mutation screening. For anesthesiological patient safety it is crucial to identify individuals at risk and warn genetic relatives; however, the legal requirements of the Patients Rights Act and the Human Genetic Examination Act must be strictly adhered to. Specific features of insurance and employment law must be respected under consideration of the Human Genetic Examination Act.     

Risikomanagement in Anästhesie und Intensivmedizin

Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.     

Onkologie in Anästhesie und operativer Intensivmedizin

Die Anaesthesiologie -     

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.     

Burn-out in An?sthesie und Intensivmedizin

Physicians and nurses in anesthesia and critical care medicine are thought to be particularly prone to developing burnout. Epidemiologic data, however, are inconclusive especially because not all of the studies presented here are methodologically sound. Nevertheless, the following conclusions appear reasonable: in several European countries burnout is seen as a relevant problem in anesthesia and critical care medicine with a point-prevalence for moderate or severe burnout, as determined with the Maslach Burnout Inventory, at approximately 30% among nurses and approximately 40-50% among physicians. Determinants correlated with burnout can be found among the individual characteristics of those affected and within the occupational realm (for example high workload and insufficient control over the work routine). The actual severity of the patients' illness does not correlate with the degree of the healthcare workers' burnout. Notwithstanding a plethora of "how to" literature, there are no preventive or therapeutic measures which could meet the scientific requirements for guidelines. Stress management programs appear to be somewhat efficacious although there are no studies to date for the clientele featured in this publication. Multimodal therapy can be recommended for pronounced burnout, including occupation-related treatment modalities. However, a general open mind towards warning signs of chronic stress disorder on the individual level as well as an adequate gratification for the work performance and sufficient control over the work routine on an organizational level appear to be among the important preventive measures.     

Anästhesie und Intensivmedizin—eine Standortbestimmung

Ohne Zusammenfassung     

Burn-out in der An?sthesie und Intensivmedizin

Background

With the demands faced by anesthetists and intensive care physicians apparently increasing continuously in Germany, the increased risk of burnout in comparison with the general working population is discussed. This debate has previously been merely speculative because of the lack of studies comparing the burn-out risk of the German working population with anesthetists. Accordingly it was not certain whether anesthetists really are at greater risk of developing burnout as has often been suggested. Moreover, age, gender, function, workplace environment, e.g. working at a hospital compared to a general practitioner (GP) surgery, may influence the risk of burnout. Therefore, this study examined whether the risk for anesthetists in Germany suffering from burnout really is greater than in other occupations. In addition, factors influencing the burnout risks of anesthetists were analyzed.

Method

A total of 3,541 questionnaires completed by German aaesthetists for a study on work satisfaction by the CBI (Copenhagen Burnout Inventory, part of the Copenhagen Psychosocial Questionnaire, COPSOQ) were analyzed. Apart from calculating the number of participants with a high risk of developing burnout syndrome, the data were used to calculate a generalized burnout score for all participants. The score was compared with data from both a random sample representing a wide variety of occupations from among the general population in Germany (n?=?4,709) and a random sample of German hospital doctors (n?=?616). In addition, subgroups were formed by gender, function (senior consultant, senior physician, specialist, junior doctor) and type and place of work (university hospital, public hospital, private clinic, GP surgery, freelance work) and the proportion of each group with a high risk of burnout syndrome was calculated. In addition, general burnout scores were compared statistically for differences among the various groups.

Results

The proportion of study participants with a high risk of burnout was 40.1%. Differences were found to exist between genders (male 37.2% versus female 46%), qualifications (senior consultant 28.9%, senior physician 38%, specialist 41.5%, junior doctor 46.7%) and working in a hospital (41.3%) compared to a GP surgery (33.2%). The random sample of hospital doctors (n?=?616) showed a burnout score of 49?±?19 (mean?±?standard deviation), compared to 44?±?19 for a random sample of the German population (n?=?4,709) and 42?±?19 for anesthetists (p??0.05). Working in a hospital was found to result in higher burnout scores than in a GP surgery or freelance work (43?±?19.2 versus 38.1?±?20.5; t(3531)?=?5.0, p?Conclusions Despite 40.1% of anesthetists being at high risk of burnout, generally speaking the risk of burnout among anesthetists was not higher than in other occupational groups in Germany. However, burnout risks for specific groups, such as female junior doctors in anesthesia, were higher and the possibility of providing social support in the workplace should be considered.     

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%.     

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.     

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.     

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.     

Anästhesie und perioperativer Schlaganfall

Ohne Zusammenfassung     

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 und Analgesie bei Suchtpatienten

Addicts have an exaggerated organic and psychological comorbidity and in cases of major operations or polytrauma they are classified as high-risk patients. Additional perioperative problems are a higher analgetics requirement, craving, physical and/or psychological withdrawal symptoms, hyperalgesia and tolerance. However, the clinical expression depends on the substance abused. For a better understanding of the necessary perioperative measures, it is helpful to classify the substances into central nervous system depressors (e.g. heroin, alcohol, sedatives, hypnotics), stimulants (e.g. cocaine, amphetamines, designer drugs) and other psychotropic substances (e.g. cannabis, hallucinogens, inhalants). The perioperative therapy should not be a therapy for the addiction, as this is senseless. On the contrary, the characteristics of this chronic disease must be accepted. Anesthesia and analgesia must be generously stress protective and sufficiently analgesically effective. Equally important perioperative treatment principles are stabilization of physical dependence by substitution with methadone (for heroin addicts) or benzodiazepines/clonidine (for alcohol, sedatives and hypnotics addiction), avoidance of stress and craving, thorough intraoperative and postoperative stress relief by using regional techniques or systematically higher than normal dosages of anesthetics and opioids, strict avoidance of inadequate dosage of analgetics, postoperative optimization of regional or systemic analgesia by non-opioids and coanalgetics and consideration of the complex physical and psychological characteristics and comorbidities. Even in cases of abstinence (clean) an inadequate dosage must be avoided as this, and not an adequate pain therapy sometimes even with strong opioids, can potentially activate addiction. A protracted abstinence syndrome after withdrawal of opioids can lead to increased response to administered opioids (e.g. analgesia, side-effects).     

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.

---

     

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.