An ideal non-invasive monitoring system should provide accurate and reproducible measurements of clinically relevant variables that enables clinicians to guide therapy accordingly. The monitor should be rapid, easy to use, readily available at the bedside, operator-independent, cost-effective and should have a minimal risk and side effect profile for patients. An example is the introduction of pulse oximetry, which has become established for non-invasive monitoring of oxygenation worldwide. A corresponding non-invasive monitoring of hemodynamics and perfusion could optimize the anesthesiological treatment to the needs in individual cases. In recent years several non-invasive technologies to monitor hemodynamics in the perioperative setting have been introduced: suprasternal Doppler ultrasound, modified windkessel function, pulse wave transit time, radial artery tonometry, thoracic bioimpedance, endotracheal bioimpedance, bioreactance, and partial CO2 rebreathing have been tested for monitoring cardiac output or stroke volume. The photoelectric finger blood volume clamp technique and respiratory variation of the plethysmography curve have been assessed for monitoring fluid responsiveness. In this manuscript meta-analyses of non-invasive monitoring technologies were performed when non-invasive monitoring technology and reference technology were comparable. The primary evaluation criterion for all studies screened was a Bland-Altman analysis. Experimental and pediatric studies were excluded, as were all studies without a non-invasive monitoring technique or studies without evaluation of cardiac output/stroke volume or fluid responsiveness. Most studies found an acceptable bias with wide limits of agreement. Thus, most non-invasive hemodynamic monitoring technologies cannot be considered to be equivalent to the respective reference method. Studies testing the impact of non-invasive hemodynamic monitoring technologies as a trend evaluation on outcome, as well as studies evaluating alternatives to the finger for capturing the raw signals for hemodynamic assessment, and, finally, studies evaluating technologies based on a flow time measurement are current topics of clinical research.

Nichtinvasive Überwachungstechniken sollen eine exakte, verlässliche, bettseitig verfügbare, kontinuierliche, einfach zu bedienende und kostengünstige Darstellung vitaler Patientenparameter in Anästhesiologie, Intensivmedizin und Notfallmedizin garantieren und dabei für die betroffenen Patienten ein minimales Risiko- bzw. Nebenwirkungsprofil besitzen. Vorbild ist die Einführung der Pulsoxymetrie, die sich weltweit zur nichtinvasiven Überwachung der Oxygenierung durchsetzen konnte. Eine entsprechende nichtinvasive Überwachung der Hämodynamik bzw. der Perfusion könnte die anästhesiologische Behandlung noch besser auf die Bedürfnisse des individuellen Einzelfalls optimieren. In den vergangenen Jahren wurde eine Reihe nichtinvasiver Überwachungstechniken (für die Herzzeitvolumen(HZV)-/Schlagvolumen(SV)-Messung: suprasternaler Dopplerultraschall, modifizierte Windkesselfunktion, Pulswellentransitzeit, Radialarterientonometrie, thorakale Bioimpedanz, endotracheale Bioimpedanz, Bioreaktanz, partielle CO2-Rückatmung; für die Vorhersage der Volumenreagibilität: fotoelektrische Fingerblutvolumenmessung, beatmungsbedingte Schwankung der Plethysmographiekurve) vorgestellt. Eine kritische Übersicht und Bewertung dieser gutachterlich geprüften Veröffentlichungen liegen bislang nicht vor. Um bei Durchführung einer Metaanalyse eine akzeptable Vergleichbarkeit zu gewährleisten, wurden daher Untersuchungen mit jeweils gleichartiger Studien- bzw. Referenzmethode zusammengefasst und betrachtet. Primäres Evaluationskriterium war das Vorliegen einer Bland-Altman-Analyse zum Vergleich von Mittelwert und Streuung im Methodenvergleich nichtinvasive Technologie vs. Referenzmethode. Für die meisten nichtinvasiven Überwachungstechniken wurde im Vergleich zur Referenztechnik eine breite Streuung der gefundenen Messwerte festgestellt. Daher erscheint eine gleichwertige Ersetzbarkeit gegenüber invasiven Überwachungstechniken hinsichtlich der Verlässlichkeit des gemessenen Einzelwerts derzeit nicht gegeben. Gegenwärtige Schwerpunkte der klinischen Forschung sind der Stellenwert nichtinvasiver Überwachungstechniken für eine Trendüberwachung, Alternativen zum Finger als Lokalisation zum Abgreifen von Rohsignalen bei der nichtinvasiven Überwachung und die Entwicklung von Fluss-Zeit-basierten Messmethoden hämodynamischer Überwachungsparameter.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality throughout the world. Despite improvements in medical care, the current clinical TBI treatment is mainly supportive and no specific neuroprotective drugs are available. TBI arises from external forces applied to the head, resulting in immediate and irreversible damage, or ‘primary injury’. In addition, early and long-lasting secondary injury cascades are triggered. Many of the debilitating functional impairments observed in patients result from the potentially preventable ‘secondary injury’. Over-activation of N-methyl-D-aspartate receptors is thought to play a key role in secondary injury. Xenon is a noble gas and general anaesthetic that is a competitive inhibitor of the N-methyl-D-aspartate receptor at the glycine binding site.1–3 Xenon has been shown to be neuroprotective in models of brain ischaemia. Much less is known about the xenon effect in the context of TBI. Our work focused on evaluating xenon’s neuroprotective efficacy in the reproducible controlled cortical impact animal model of blunt TBI, which includes elements found after moderate to severe TBI in humans, such as contusional lesion, brain oedema, elevated intracranial pressure, and neurological impairment. Adult C57BL/6 male mice (n=196) were fixed in a stereotactic frame under anaesthesia (sevoflurane 3.5% and buprenorphine s.c. 0.1 mg/kg) and underwent a right parietal cortical impact, delivered by a custom-made electropneumatic impactor with a 3-mm-diameter flat tip perpendicular to the brain surface. Impact velocity of 8 m s–1, impact duration of 150 ms, and brain-penetration depth of 1.0 mm were used. Throughout the procedure, the core body temperature was monitored and feedback controlled. The animals were randomly assigned to control (75% nitrogen:25% oxygen) and xenon treated (30%, 50%, or 75% xenon:25% oxygen, balanced with nitrogen) groups. Short-term and long-term outcomes, both functional and histological, were measured by researchers blinded to the treatment. The statistical significance was assessed with one-way and two-way analyses of variance with Bonferroni’s post hoc test. Our study showed 75% xenon significantly (P<0.05) reduced the contusion volume 24 h after injury, and significantly (P<0.05) improved the neurological outcome up to 4 days after injury and clinically relevant locomotor parameters 1 month after injury. Xenon treatment significantly (P<0.05) reduced the contusion volume when given up to 3 h after injury, and significantly (P<0.05) improved the neurological outcome when given up to 1 h after injury. Significant (P<0.05) reductions in the contusion volume and improvement in the neurological outcome 24 h after injury were also achieved with 30% and 50% xenon concentrations. Our results show in an animal model of TBI that xenon improves the functional outcomes and reduces the contusion volume. We demonstrated both a reduction in the development of secondary injury and an improvement in long-term translationally relevant motor outcomes. Our findings, including the demonstration of long-term neuroprotection and a clinically relevant therapeutic time window, support the idea that xenon may be of benefit as a neuroprotective treatment in TBI patients. 1.Armstrong SP, Banks P, McKitrick TJW, et al. Anesthesiology 2012; 117: 38–472.Dickinson R, Peterson BK, Banks P, et al. Anesthesiology 2007; 107: 756–673.Franks NP, Dickinson R, de Sousa SL, Hall AC, Lieb WR. Nature 1998; 396: 324

Simulation is an established instrument for medical training and further education covering technical and non-technical skills. It provides a platform for training psychomotor skills and professional behavior. Various simulators have been developed for cardiac, thoracic, and vascular surgery. Skill trainers are described for heart valve surgery and coronary anastomoses. Even beating artificial hearts are commercially available for surgical training, besides classical animal models. Virtual reality provides an additional dimension for training in thoracoscopic and interventional surgery. Every simulator has to be embedded in a defined curriculum to achieve the optimal effect. Curricula in the form of courses may be more effective in teaching basic surgical skills than learning solely during patient treatment in the operating room. One popular method to facilitate simulators for education is scenario training in real time. International associations recommend the implementation of scenario simulation for emergency training and evaluation of surgical skills in various disciplines. Issues, such as communication, team leadership and decision making can be effectively trained by simulation scenarios. There are only a few but fundamental publications providing evidence that simulation has a positive effect on patient care during cardiac surgery and on intensive care units; however, simulation can never replace experience in real patient care. Especially inexperienced healthcare providers have a tendency to overestimate their competence after training by simulation. Simulation is therefore a valuable adjunct but not a substitute for medical training and further education.

seit Jahren engagieren sich an vielen Orten in Deutschland Kolleginnen und Kollegen aus der Anästhesiologie, um die Quote der erfolgreichen Reanimationen zu erhöhen. All diesen Kollegen, seien sie nun primär im wissenschaftlichen Bereich, in der praktischen Arbeit, in der Ausbildung oder auch in der Laienausbildung aktiv, gebühren unser Dank und unsere große Anerkennung. Die Erfolge der Bemühungen können in dem seit fast einem Jahrzehnt bestehenden deutschen Reanimationsregister nachvollzogen werden (http://www.Reanimationsregister.de sowie http://www.100-pro-reanimation.de).

SummaryTrendelenburg positioning in combination with pneumoperitoneum during robotic‐assisted prostatic surgery possibly impairs cerebrovascular autoregulation. If cerebrovascular autoregulation is disturbed, arterial hypertension might induce cerebral hyperaemia and brain oedema, while low arterial blood pressure can induce cerebral ischaemia. The time course of cerebrovascular autoregulation was investigated during use of the Trendelenburg position and a pneumoperitoneum for robotic‐assisted prostatic surgery using transcranial Doppler ultrasound. Cerebral blood flow velocity was correlated with arterial blood pressure and the autoregulation index (Mx) was calculated. In 23 male patients, Mx was assessed at baseline, after induction of general anaesthesia, during the Trendelenburg position (40–45°), and after repositioning. During the Trendelenburg position, Mx increased over time, indicating an impairment of cerebrovascular autoregulation. After repositioning, Mx recovered to baseline levels. It can be concluded that with longer durations of Trendelenburg position and pneumoperitoneum, cerebrovascular autoregulation deteriorates, and, therefore, blood pressure management should be adapted to avoid cerebral oedema and the duration of Trendelenburg position should be as short as possible.

BACKGROUND Cyclic recruitment and derecruitment (R/D) play a key role in the pathomechanism of acute lung injury (ALI) leading to respiration-dependent oscillations of arterial partial pressure of oxygen (Pa(O(2))). These Pa(O(2)) oscillations could also be forwarded to the cerebral microcirculation. METHODS In 12 pigs, partial pressure of oxygen was measured in the thoracic aorta (Pa(O(2))) and subcortical cerebral tissue (Pbr(O(2))). Cerebral cortical haemoglobin oxygen saturation (Sbr(O(2))), cerebral blood flow (CBF), and peripheral haemoglobin saturation (Sp(O(2))) were assessed by spectroscopy and laser Doppler flowmetry. Measurements at different fractions of inspired oxygen (F(I(O(2)))) were performed at baseline and during cyclic R/D. STATISTICS frequency domain analysis, the Mann-Whitney test, linear models to test the influence of Pa(O(2)) and systolic arterial pressure (SAP) oscillations on cerebral measurements. RESULTS Parameters [mean (SD)] remained stable during baseline. Pa(O(2)) oscillations [10.6 (8) kPa, phase(reference)], systemic arterial pressure (SAP) oscillations [20 (9) mm Hg, phase(Pa(O(2))-SAP) -33 (72)°], and Sp(O(2))oscillations [1.9 (1.7)%, phase(Pa(O(2))-Sp(O(2))) 264 (72)°] were detected during lung R/D at 1.0. Pa(O(2)) oscillations decreased [2.7 (3.5) kPa, P=0.0008] and Sp(O(2)) oscillations increased [6.8 (3.9)%, P=0.0014] at F(I(O(2))) 0.3. In the brain, synchronized Pbr(O(2)) oscillations [0.6 (0.4) kPa, phase(Pa(O(2))-Pbr(O(2))) 90 (39)°], Sbr(O(2)) oscillations [4.1 (1.5)%, phase(Pa(O(2))-Sbr(O(2))) 182 (54)°], and CBF oscillations [198 (176) AU, phase(Pa(O(2))-CBF) 201 (63)°] occurred that were dependent on Pa(O(2)) and SAP oscillations. CONCLUSIONS Pa(O(2)) oscillations caused by cyclic R/D are transmitted to the cerebral microcirculation in a porcine model of ALI. These cyclic oxygen alterations could play a role in the crosstalk of acute lung and brain injury.

Diabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.

Hintergrund und Fragestellung: Die Bereitschaft zur Organspende ist in Deutschland nach wie vor unzureichend und bei Weitem erhalten nicht alle Patienten auf den Wartelisten rechtzeitig ein geeignetes Spenderorgan. So wird angenommen, dass die inadäquate Verfügbarkeit von Spenderorganen Ausdruck mangelnder Kenntnis und nachfolgender Unsicherheit in der Bevölkerung ist. Die Einstellung und das Wissen junger Menschen zur Organspende sind bislang wenig untersucht. Methodik: 4000 Fragebögen wurden über die Schulen an alle Schülerinnen und Schüler der 11. und 12. Klasse (n = 2422) in der rheinland-pfälzischen Landeshauptstadt Mainz versandt. Die Beantwortung von 12 Fragen erfolgte unter Aufsicht eines Lehrers sowie ohne Hilfsmittel und war freiwillig. Ergebnisse: 1155 Umfragebögen wurden ausgewertet. 11,3 % aller antwortenden Teilnehmer besaßen einen Organspendeausweis. In 48,9 % der Fälle waren Hirntod und Organspende in den eigenen Familien bereits thematisiert worden. 37,0 % der Schüler wären im Falle ihres Hintodes nicht mit einer Organspende einverstanden und geben hierfür in 72,4 % ein Informationsdefizit als Grund an. Schüler mit ausländischer Staatsbürgerschaft lehnen die Organspende häufiger ab als Deutsche (43,4 % vs. 36,2 %). Folgerungen: Mehr als die Hälfte der Jugendlichen zwischen 14 und 20 Jahren befürworten die Organspende. Allerdings führen junge Menschen nur selten einen Organspendeausweis. Diese regionalen Ergebnisse zeigen, dass ein Informationsdefizit der Hauptgrund für die Ablehnung zur Organspendebereitschaft ist. Eine Intensivierung der Aufklärung im Schulalter sollte zu einer Verbesserung dieser Situation führen.