Anaesthesia has become progressively safer through standardisation, technological advances, and pharmacological refinement. Paradoxically, the practical diversity of anaesthetic drugs available for routine clinical use is narrowing because of regulatory decisions, environmental policies, procurement pressures, market withdrawals, and professional convergence on default regimens. Although standardisation improves reliability, excessive pharmacological contraction can reduce clinical resilience, erode training competence with alternative agents, and increase vulnerability to shortages or context-specific contraindications. Stimulated by recent commentary that desflurane abandonment is only one component of a comprehensive sustainability strategy in anaesthesia, we argue that pharmacological diversity represents a form of preparedness: maintaining second-line and context-specific options is not inefficiency but a safeguard for patient-centred, adaptable care.

Die Anästhesiologie war traditionell ein Fach mit breitem pharmakologischem Spektrum. In den vergangenen Jahren zeigt sich jedoch eine deutliche Tendenz zur Reduktion dieses Instrumentariums. Zahlreiche etablierte Substanzen haben in vielen Kliniken an Bedeutung verloren oder sind vollständig aus dem klinischen Alltag verschwunden. Dieser Rückgang beruht nur teilweise auf neuer Evidenz – häufiger spielen didaktische Vereinfachung, kulturelle Standardisierung, ökologische Diskussionen und regulatorische Eingriffe von Behörden eine entscheidende Rolle. Der Beitrag analysiert Ursachen und Mechanismen dieser therapeutischen Verarmung und vergleicht die Entwicklungen mit anderen medizinischen Disziplinen. Abschließend werden Wege aufgezeigt, wie eine indikationsbezogene, evidenzorientierte und differenzierte Pharmakotherapie in der Anästhesiologie wieder gestärkt werden kann.

BACKGROUND Anaesthesia is central to obstetric care, yet contemporary data on clinical practices, particularly concerning general anaesthesia (GA) for caesarean section (CS), remain scarce. Given evolving guidelines and technologies, an updated understanding of real-world anaesthetic management is needed. OBJECTIVE Our aim was to evaluate current anaesthetic practices in obstetric care in Germany, focusing on the use of GA for CS, perioperative management, and adherence to guideline recommendations. DESIGN Nationwide, anonymised, cross-sectional questionnaire survey. SETTING The questionnaire targeted both experienced obstetric anaesthesiologists and other anaesthesiologists regularly working in obstetric anaesthesia in German hospitals. PARTICIPANTS We analysed 567 completed questionnaires from anaesthesiologists actively involved in obstetric care, representing 171 geographic locations and institutions covering approximately half of all annual births in Germany. MAIN OUTCOME MEASURES Contraindications for neuraxial procedures, estimated GA rates, perioperative management strategies, and conformity with guidelines. RESULTS The survey yielded 29 984 individual responses. Neuraxial anaesthesia was strongly preferred over GA (Likert score 4.8/5), with a median GA rate of 5 [5 to 10]%. Postoperative nausea and vomiting prophylaxis was provided by 89.4% of respondents. Platelet thresholds for neuraxial anaesthesia were more liberal than in previous surveys, with reliance on individual risk-benefit assessment instead of fixed numerical thresholds. For GA induction, propofol has largely replaced thiopental, but suxamethonium remains the favoured neuromuscular blocking agent (71.7%). Balanced anaesthesia with sevoflurane predominated (84%), while nitrous oxide use has declined sharply (2.1%). Gaps in guideline adherence were noted regarding the timing of antibiotic prophylaxis, the use of active warming and intraoperative red blood cell salvage. Compared with international practice, postoperative analgesia was mainly opioid-based, with regional techniques underused (23%). CONCLUSIONS Despite progress towards guideline adherence, substantial gaps persist between recommendations and clinical practice in German obstetric anaesthesia. Improvement opportunities include better implementation of evidence-based perioperative strategies and greater use of regional analgesic techniques postoperatively.

BACKGROUND:Anaesthesia is central to obstetric care, yet contemporary data on clinical practices, particularly concerning general anaesthesia (GA) for caesarean section (CS), remain scarce. Given evolving guidelines and technologies, an updated understanding of real-world anaesthetic management is needed. OBJECTIVE:Our aim was to evaluate current anaesthetic practices in obstetric care in Germany, focusing on the use of GA for CS, perioperative management, and adherence to guideline recommendations. DESIGN:Nationwide, anonymised, cross-sectional questionnaire survey. SETTING:The questionnaire targeted both experienced obstetric anaesthesiologists and other anaesthesiologists regularly working in obstetric anaesthesia in German hospitals. PARTICIPANTS:We analysed 567 completed questionnaires from anaesthesiologists actively involved in obstetric care, representing 171 geographic locations and institutions covering approximately half of all annual births in Germany. MAIN OUTCOME MEASURES:Contraindications for neuraxial procedures, estimated GA rates, perioperative management strategies, and conformity with guidelines. RESULTS:The survey yielded 29 984 individual responses. Neuraxial anaesthesia was strongly preferred over GA (Likert score 4.8/5), with a median GA rate of 5 [5 to 10]%. Postoperative nausea and vomiting prophylaxis was provided by 89.4% of respondents. Platelet thresholds for neuraxial anaesthesia were more liberal than in previous surveys, with reliance on individual risk-benefit assessment instead of fixed numerical thresholds. For GA induction, propofol has largely replaced thiopental, but suxamethonium remains the favoured neuromuscular blocking agent (71.7%). Balanced anaesthesia with sevoflurane predominated (84%), while nitrous oxide use has declined sharply (2.1%). Gaps in guideline adherence were noted regarding the timing of antibiotic prophylaxis, the use of active warming and intraoperative red blood cell salvage. Compared with international practice, postoperative analgesia was mainly opioid-based, with regional techniques underused (23%). CONCLUSIONS:Despite progress towards guideline adherence, substantial gaps persist between recommendations and clinical practice in German obstetric anaesthesia. Improvement opportunities include better implementation of evidence-based perioperative strategies and greater use of regional analgesic techniques postoperatively.

Traditionally, anesthesiology has been a discipline with a broad pharmacological spectrum. In recent years, however, there has been a clear trend toward reducing this range of therapeutic options. Numerous well-established agents have lost importance in many hospitals or have disappeared entirely from the routine clinical practice. This decline is only partly based on new evidence, more often, didactic simplification, cultural standardization, ecological discussions and regulatory interventions by authorities play a decisive role. This article analyzes the causes and mechanisms of this therapeutic impoverishment and compares these developments with other medical disciplines. Finally, it outlines ways in which indication-based, evidence-oriented and differentiated pharmacotherapy in anesthesiology can be strengthened once again.

On May 4, 2024, the 23rd Obstetric Anesthesia Symposium took place as an event of the scientific working group "Obstetric Anesthesia" of the German Society of Anesthesiology (DGAI). As in previous years, topics related to obstetric anesthesiological practice were presented by experienced speakers and intensively discussed with the participants. Among other things, personal "recipes" and recommendations for daily practice, various options for analgesia in the delivery room, patient blood management in the delivery room, alternatives to obstetric epidurals, management of post-puncture headaches, and analgesia after cesarean section were addressed.

On May 4, 2024, the 23rd Obstetric Anesthesia Symposium took place as an event of the scientific working group "Obstetric Anesthesia" of the German Society of Anesthesiology (DGAI). As in previous years, topics related to obstetric anesthesiological practice were presented by experienced speakers and intensively discussed with the participants. Among other things, personal "recipes" and recommendations for daily practice, various options for analgesia in the delivery room, patient blood management in the delivery room, alternatives to obstetric epidurals, management of post-puncture headaches, and analgesia after cesarean section were addressed.

Objective: Postoperative nausea and vomiting (PONV) occurs in up to 30% of patients and its pathophysiology and mechanisms have not been completely described. Hypotension and a decrease in cardiac output are suspected to induce nausea. The hypothesis that intraoperative hypotension might influence the incidence of PONV was investigated. Material and methods: The study was conducted as a retrospective large single center cohort study. The incidence of PONV was investigated until discharge from post anesthesia care unit (PACU). Surgical patients with general anesthesia during a 2-year period between 2018 and 2019 at a university hospital in Germany were included. Groups were defined based on the lowest documented mean arterial pressure (MAP) with group H50: MAP <50mmHg; group H60: MAP <60mmHg; group H70: MAP <70mmHg, and group H0: no MAP <70mmHg. Decreases of MAP in the different groups were related to PONV. Propensity-score matching was carried out to control for overlapping risk factors. Results: In the 2-year period 18.674 patients fit the inclusion criteria. The overall incidence of PONV was 11%. Patients with hypotension had a significantly increased incidence of PONV (H0 vs. H50: 11.0% vs.17.4%, Risk Ratio (RR): 1.285 (99%CI: 1.102-1.498), p < 0.001; H0 vs. H60: 10.4% vs. 13.5%, RR: 1.1852 (99%CI: 1.0665-1.3172), p < 0.001; H0 vs. H70: 9.4% vs. 11.2%, RR: 1.1236 (99%CI: 1.013 - 1.2454); p = 0.0027). Conclusion: The study demonstrates an association between intraoperative hypotension and early PONV. A more severe decrease of MAP had a pronounced effect.

Abstract Objective Intraoperative arterial hypotension (IOH) is associated with poor patient outcome. This study aims to compare the hemodynamic effects of Cafedrine/Theodrenaline (C/T) and Noradrenaline (NA) for the treatment of hypotension in patients who develop IOH after anesthesia induction. Research design and methods This is a national, randomized, parallel-group, multicenter, and open-label study. Adult patients (≥50 years, ASA-classification III–IV) who undergo elective surgery will be included. When IOH (MAP <70 mmHg) develops, C/T or NA will be given as a bolus injection (“bolus phase”, 0–20 min after initial application) and subsequently as continuous infusion (“infusion phase”, 21–40 min after initial application) to achieve MAP = 90 mmHg. Hemodynamic data are captured in real time by advanced hemodynamic monitoring. Results Primary endpoints, i.e. the treatment-related difference in average mean arterial pressure (MAP) during the “infusion phase” and the treatment-related difference in average cardiac index during the “bolus phase” are assessed (fixed-sequence method). Non-inferiority of C/T compared to NA in achieving 90 mmHg (MAP) when applied as continuous infusion is hypothesized. In addition, superiority of C/T over NA, applied as bolus injection, in increasing cardiac index is postulated. It is estimated that 172 patients are required to establish statistical significance with a power of 90%. After adjusting for ineligibility and dropout rate, 220 patients will be screened. Conclusion This clinical trial will yield evidence for marketing authorization of C/T applied as continuous infusion. Additionally, the effects of C/T compared to NA on cardiac index will be assessed. First results of the “HERO”-study are expected in 2024. DRKS identifier: DRKS00028589. EudraCT identifier: 2021-001954-76.

( Eur J Anaesthesiol . 2022;39:236–243) Supine hypotensive syndrome was first described in 1953, which was used to describe acute hypotension associated with pallor, sweating, increased femoral venous pressure, and increased pulse rate during pregnancy when lying in a supine position for 3 to 7 minutes. It continues to be a peripartum challenge in the field of obstetrics today, and the use of the 15 degrees lateral tilt (first introduced in the 1970s) during labor and cesarean section remains a mandatory clinical practice worldwide. Modern physiological and anatomic knowledge prompts a reassessment of guidelines regarding supine hypotensive syndrome of pregnancy. This review looks at the definition and physiology of supine hypotensive syndrome; symptomatic vs. asymptomatic parturients; hemodynamic measurements and compression of the aorta when in the supine position; maternal position and fetal compromise; and implications for obstetric anesthesia.

Background: Increased vascular permeability is a characteristic feature of sepsis which, in the past, has been ascribed exclusively to a malfunction of endothelial cells. However, recently it has become evident that the endothelial glycocalyx is of considerable importance concerning various aspects of vascular physiology, e.g. the vascular barrier and inflammation. Heparan sulfate, one of its essential components is characteristically traceable in blood, in case the endothelial glycocalyx is damaged or destroyed.Methods: In 15 pigs we investigated whether the administration of endotoxin from gram-negative bacteria (Escherichia coli) result, in increased serum levels of heparan sulfate, signalizing a shedding of the glycocalyx. In addition, markers of inflammation (white blood cell count, platelet count, turnout necrosis factor-alpha and interleukin-6) were evaluated over an observation period of 6 hours.Results: Serum heparan sulfate concentrations significantly increased over time in. the endotoxin group and were significantly elevated in comparison to the control group 6 hours after administration of endotoxin (p<0.001). In the endotoxin group all markets of inflammation significantly changed during the time course.Conclusions: The administration of bacterial endotoxin induced a significant rise in degradation products Of the endothelial glycocalyx.

Background: Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma. Methods: This systematic review and meta-analysis was registered at PROSPERO (CRD42018100379). We included 85 fully published articles from 1980 to June 2018 according to the protocol and three additional recent articles up to June 2020 in English, French, German, and Spanish reporting on prospective, randomised, and controlled clinical trials applying volume therapy with HES 130/0.4 or HES 130/0.42, including combinations with crystalloids, to patients undergoing surgery. Comparators were albumin, gelatin, and crystalloids only. A meta-analysis could not be performed for the two trauma studies as there was only one study that reported data on endpoints of interest. Results: Surgical patients treated with HES had lower postoperative serum creatinine (P<0.001) and showed no differences in renal dysfunction, renal failure, or renal replacement therapy. Although there was practically no further difference in the colloids albumin or gelatin, the use of HES improved haemodynamic stability, reduced need for vasopressors (P<0.001), and decreased length of hospital stay (P<0.001) compared with the use of crystalloids alone. Conclusions: HES was shown to be safe and efficacious in the perioperative setting. Results of the present meta-analysis suggest that when used with adequate indication, a combination of intravenous fluid therapy with crystalloids and volume replacement with HES as colloid has clinically beneficial effects over using crystalloids only.

Anaesthetists play a major role in the perioperative treatment of patients, sharing responsibility for quality and safety in anaesthesia, intensive care, emergency and pain medicine. Several aspects lead to the fact that these issues are particularly important in obstetric anaesthesia. As morbidity and mortality are dramatically higher than in a nonpregnant population in this age, there is room for improvement even in regions with a well-developed healthcare system. Adverse events and complications during birth often hit fast, hard and unexpectedly and require immediate patient-centred care. This mostly involves an interdisciplinary and interprofessional approach that includes obstetricians, neonatologists, anaesthetists, intensivists and of course midwives and nurses. In this article, established standards and emerging possibilities to improve patient safety by developing a culture of awareness for safety aspects, education, establishing safety and communication strategies and performing teamwork- and simulation training are discussed. Apart from these issues, self-care of clinicians is vital in the prevention of adverse events, because fatigue and burnout are associated with increased rates of complications.

A rational infusion therapy orchestrates fluid- and volume therapy based on the individual indication and situation. The principle of fluid replacement is to substitute ongoing fluid losses such as insensible perspiration and urine output or to treat dehydration with balanced crystalloid solutions. Volume therapy in contrast is the quick restoration of intravascular losses such as an acute blood loss through application of balanced colloids or crystalloids. The goal of volume therapy is to maintain normal cardiac output and oxygen delivery by restoring intravascular normovolemia and cardiac preload. Whether colloid or crystalloid infusions are most suitable for volume therapy remains unclear. Most trials in this field are either underpowered or used colloids in inadequate situations, patients and amounts. Two major trials from the European Society of Anaesthesiology and Intensive Care (ESAIC) are underway that seem promising to provide evidence in this emotional debate.

BACKGROUND:Hypotension and bradycardia are known side effects of general anesthesia, while little is known about further macro- and microhemodynamic changes during induction. Intriguing is furthermore, why some patients require no vasopressor medication to uphold mean arterial pressure, while others need vasopressor support.OBJECTIVE:Determination of macro- and microhemodynamic changes during induction of general anesthesia.METHODS:We enrolled 150 female adults scheduled for gynaecological surgery into this prospective observational, single-blinded trial. Besides routinely measuring heart rate (HR) and mean arterial blood pressure (MAP), the non-invasive technique of thoracic electrical bioimpedance was applied to measure cardiac output (CO), cardiac index (CI), stroke volume (SV), stroke volume variability (SVV) and index of myocardial contractility (ICON) before induction of anesthesia, 7 times during induction, and, finally, after surgery in the recovery room. Changes in microcirculation were assessed using sidestream dark field imaging to establish the perfused boundary region (PBR), a validated gauge of glycocalyx health. Comparisons were made with Friedman's or Wilcoxon test for paired data, and with Mann-Whitney-U test for unpaired data, with post-hoc corrections for multiple measurements by the Holm-Bonferroni method.RESULTS:83 patients did not need vasopressor support, whereas 67 patients required therapy (norepinephrine, atropine or cafedrine/theodrenaline) to elevate MAP values to ≥70mmHg during induction, 54 of these receiving norepinephrine (NE) alone. Pre-interventional (basal) values of CO, CI, ICON, SV and SVV were all significantly lower in the group of patients later requiring NE (p < 0.04), whereas HR and MAP were identical for both groups. HR, MAP and CO decreased from baseline to 12 min after induction of general anesthesia in both the patients without and those with NE support. Heart rate decreased significantly by about 25% in both groups (-19 to -21 bpm). The median individual decrease of MAP amounted to -26.7% (19.7/33.3, p < 0.001) and -26.1% (11.6/33.2, p < 0.001), respectively, whereas for CO it was -40.7% (34.1/50.1, p < 0.001) and -43.5% (34.8/48.7). While these relative changes did not differ between the two groups, in absolute values there were significantly greater decreases in CO, CI, SV and ICON in the group requiring NE. Noteably, NE did not restore ICON or the other cardiac parameters to levels approaching those of the group without NE. PBR was measured in a total of 84 patients compiled from both groups, there being no intergroup differences. It increased 6.4% (p < 0.001) from pre-induction to the end of the operation, indicative of damage to microvascular glycocalyx.CONCLUSION:Non-invasive determination of CO provides additional hemodynamic information during anesthesia, showing that induction results in a significant decrease not only of MAP but also of CO and other cardiac factors at all timepoints compared to baseline values. The decrease of CO was greater than that of MAP and, in contrast to MAP, did not respond to NE. There was also no sign of a positive inotropic effect of NE in this situation. Support of MAP by NE must consequently result from an increase in peripheral arterial resistance, posing a risk for oxygen supply to tissue. In addition, general anesthesia and the operative stimulus lead to an impairment of the microcirculation.

Background: Mannitol and hypertonic saline are widely used to treat raised intracranial pressure (ICP) after traumatic brain injury (TBI), but the clinical superiority of one over the other has not been demonstrated. Methods: According to the PRISMA statement, this meta-analysis reports on randomized controlled trials investigating hypertonic saline compared with mannitol in the treatment of elevated ICP following TBI. The protocol for the literature searches (Medline, Embase, Central databases), quality assessment, endpoints (mortality, favorable outcome, brain perfusion parameters), and statistical analysis plan (including a trial sequential analysis) were prospectively specified and registered on the PROSPERO database (CRD42017057112). Results: A total of 12 randomized controlled trials with 464 patients were eligible for inclusion in this analysis. Although there was a nonsignificant trend in favor of hypertonic saline, there were no significant differences in mortality between the 2 treatments (relative risk [RR]: 0.69, 95% confidence interval [CI]: 0.45, 1.04; P=0.08). There were also no significant differences in favorable neurological outcome between hypertonic saline (HS) and mannitol (RR: 1.28, 95% CI: 0.86, 1.90; P=0.23). There was no difference in ICP at 30 to 60 minutes after treatment (mean difference [MD]: -0.19 mm Hg, 95% CI: -0.54, 0.17; P=0.30), whereas ICP was significantly lower after HS compared with mannitol at 90 to 120 minutes (MD: -2.33 mm Hg, 95% CI: -3.17, -1.50; P<0.00001). Cerebral perfusion pressure was higher between 30 to 60 and 90 to 120 minutes after treatment with HS compared with after treatment with mannitol (MD: 5.48 mm Hg, 95% CI: 4.84, 6.12; P<0.00001 and 9.08 mm Hg, 95% CI: 7.54, 10.62; P<0.00001, respectively). Trial sequential analysis showed that the number of cases was insufficient to produce reliable statements on long-term outcomes. Conclusion: There are indications that HS might be superior to mannitol in the treatment of TBI-related raised ICP. However, there are insufficient data to reach a definitive conclusion, and further studies are warranted.

Zusammenfassung Hintergrund Im Rahmen der Pandemie des SARS-CoV-2-Virus erlangte das Patientenkollektiv der Schwangeren früh Aufmerksamkeit. Initial wurde angesichts sich früh abzeichnender Krankheitsfälle bei jüngeren Patienten mit einem erheblichen Aufkommen peripartal zu betreuender, COVID-19-positiver Schwangerer gerechnet. Ziel der Arbeit Diese Arbeit vermittelt einen Einblick in die SARS-CoV-2-Infektionszahlen im Rahmen der geburtshilflichen Anästhesie zu Beginn der Pandemie sowie während der zweiten Infektionswelle in Deutschland. Methoden Über das COALA-Register (COVID-19 related Obstetric Anaesthesia Longitudinal Assessment-Registry) wurden sowohl von März bis Mai 2020 als auch von Oktober 2020 bis Februar 2021 in Deutschland und der Schweiz wöchentlich prospektiv Daten zu Verdachts- und bestätigten SARS-CoV-2-Fällen bei Schwangeren zum Zeitpunkt der Geburt erhoben. Betrachtet wurden die Verteilung dieser auf die Anzahl der Geburten, Zentren und Erhebungswochen sowie mütterliche Charakteristika und Krankheitsverläufe. Ergebnisse Neun Zentren haben im Verlauf 44 SARS-CoV-2-positive Schwangere zum Zeitpunkt der Geburt bei 7167 Geburten (0,6 %) gemeldet (3 Fälle auf 2270 Geburten (0,4 %) und 41 Fälle auf 4897 Geburten (0,8 %)). Berichtet wurden 2 schwere COVID-19-Verläufe ( n = 1 mit Todesfolge nach ECMO, n = 1 mit ECMO überlebt). Bei 28 (68 %) Patientinnen verlief die Infektion asymptomatisch. Ein Neugeborenes wurde im Verlauf positiv auf SARS-CoV‑2 getestet. Schlussfolgerung Mithilfe des Registers konnte das Auftreten von Fällen zu Beginn der Pandemie zeitnah eingeschätzt werden. Es traten sporadisch Verdachtsfälle bzw. bestätigte Fälle auf. Aufgrund fehlender flächendeckender Testung muss aber von einer Dunkelziffer asymptomatischer Fälle ausgegangen werden. Während der zweiten Infektionswelle wurden 68 % asymptomatische Fälle gemeldet. Jedoch kann es bei jungen, gesunden Patientinnen ohne das Vorliegen typischer Risikofaktoren zu schwerwiegenden Verläufen kommen.