Zusammenfassung Hintergrund Zur Erhöhung der Patientensicherheit sind verschiedene Instrumente wie etwa das „Critical Incident Reporting System“ (CIRS) oder die Verwendung des „Situation, Background, Assessment, Recommendation (SBAR) System“ entwickelt worden. Ziel war es zu ermitteln, wie Anästhesisten in Deutschland die Sicherheitskultur empfinden, und ob CIRS oder SBAR etabliert sind. Methodik Alle registrierten Mitglieder der anästhesiologischen Berufsverbände wurden zu einer Onlineumfrage zum Thema „Patientensicherheit“ eingeladen. Es wurden die Themengebiete Sicherheitskultur, CIRS und SBAR erfragt. Ergebnisse Die Bewertung der Sicherheitskultur der Anästhesieabteilung war in 76,6 % der Fälle positiv (gesamtes Krankenhaus 54,3 %). Fehlerhafte Verläufe wurden laut 76,5 % offen kommuniziert. 23 % haben den Eindruck, dass bei Fehlern die betreffende Person bloßgestellt würde. Bei einem Drittel finden keine Morbiditäts- und Mortalitäts(M&M)-Konferenzen statt. CIRS ist 98,9 % der Befragten bekannt; bei 84,4 % existiert es. CIRS-Meldungen wurden bereits von 54,4 % abgegeben. Regelmäßiges Feedback zu Meldungen erhalten nur 29,4 %. SBAR als Übergabehilfsmittel war 63,7 % unbekannt. 86,1 % halten die Verwendung eines Instruments zur Verbesserung der Übergabequalität für notwendig. Schlussfolgerungen Die Qualität der Sicherheitskultur von Anästhesieabteilungen wird positiver bewertet als die des übrigen Krankenhauses. M&M-Konferenzen sollten größere Verbreitung erfahren. CIRS ist nahezu allen befragten Anästhesisten bekannt – Feedback erfolgt selten. Es fehlt an Feedbackmechanismen für den Meldenden. Zur Implementierung von Hilfsmitteln für strukturierte Patientenübergaben sollten in Zukunft mehr Anstrengungen unternommen werden.

Anesthetic procedures may lead to severe and potentially life-threatening complications (e.g. difficult airway, allergic reactions, malignant hyperthermia). Most complications can be avoided in future anesthetic procedures with adequate preparation (e.g. awake intubation, trigger-free anesthesia). In Germany, anesthesia problem cards were introduced two decades ago to identify patients at risk and to increase patient safety by creating a standardized documentation system for anesthesia-related complications. The purpose of our study was to evaluate the utility and problems of anesthesia problem cards in clinical practice. All registered members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) (n= 19,042) were invited to participate in an online survey on patient safety. A subsection of the survey focused specifically on anesthesia problem cards and their utility in clinical practice (e.g. field of application, issuing procedures, benefits and problems). The survey subsection on anesthesia problem cards was completed by 1783 participants. Most agreed that anesthesia problem cards are a useful tool to increase patient safety (n= 1502; 84.2%) and that they are routinely issued after the occurrence of anesthesia-related complications (n= 1664, 93.4%). One of the major problems noted was that patients frequently forget to bring their anesthesia problem cards when presenting for the preanesthetic assessment. This was observed by 1457 participants (81.7%). Furthermore, the information provided on anesthesia problem cards may be inadequately phrased (n= 874; 49.0%) or illegible (n= 833; 46.7%). In addition, the space for individual comments or problem solutions is insufficient (n= 811; 45.5%). Replacements for lost anesthesia problem cards with identical informational content can be issued in only 41.9% (n= 747) of the participants' departments. Anesthesia problem cards are considered a useful tool to increase patient safety and are frequently issued in clinical practice; however, in the document's current form its full potential for risk minimization cannot be exploited. Structural changes are required to increase documentation quality and reproducibility. Concerning its informational content, the spectrum of included complications and their individual solutions need to be expanded to meet the requirements of modern anesthetic practice.

Der Anästhesieausweis wurde eingeführt, um Risikopatienten zu identifizieren und die Patientensicherheit durch eine standardisierte Dokumentation von Narkosezwischenfällen zu steigern. Das Ziel der vorliegenden Arbeit ist, den Nutzen und mögliche Probleme des Anästhesieausweises in der klinischen Anwendung zu untersuchen.

Knowledge about placebo mechanisms in patients with chronic pain is scarce. Fibromyalgia syndrome (FM) is associated with dysfunctions of central pain inhibition, and because placebo analgesia entails activation of endogenous pain inhibition, we hypothesized that long-term exposure to FM pain would negatively affect placebo responses. In our study we examined the placebo group (n = 37, mean age 45 years) from a 12-week, randomized, double-blind, placebo-controlled trial investigating the effects of milnacipran or placebo. Twenty-two patients were classified as placebo non responders and 15 as responders, according to the Patient Global Impression of Change scale. Primary outcome was the change in pressure pain sensitivity from baseline to post-treatment. Secondary outcomes included ratings of clinical pain (visual analog scale), FM effect (Fibromyalgia Impact Questionnaire), and pain drawing. Among placebo responders, longer FM duration was associated with smaller reductions in pressure pain sensitivity (r=.689, P=.004), but not among nonresponders (r=.348, P=.112). In our study we showed that FM duration influences endogenous pain regulation, because pain levels and placebo-induced analgesia were negatively affected. Our results point to the importance of early FM interventions, because endogenous pain regulation may still be harnessed at that early time. Also, placebo-controlled trials should take FM duration into consideration when interpreting results.Perspective: This study presents a novel perspective on placebo analgesia, because placebo responses among patients with chronic pain were analyzed. Long-term exposure to fibromyalgia pain was associated with lower placebo analgesia, and the results show the importance of taking pain duration into account when interpreting the results from placebo-controlled trials. (C) 2017 The Authors. Published by Elsevier Inc. on behalf of the American Pain Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Purpose Toxic reactions to local anesthetics are rare but potentially lethal. In fact, animal studies and case reports demonstrate that the administration of lipid emulsions after initializing cardiopulmonary resuscitation is a promising treatment option. The aim of this study was to determine how many hospitals in Germany are prepared to treat toxic reactions to local anesthetics with lipid infusion and to identify how often and what type of toxic reactions occur and if treatment was successful. Further, we aimed to elucidate if current guidelines lead to more immediate availability of lipid emulsions in direct proximity to the room where regional anesthesia is performed. Methods A standardized survey was sent to 1,305 German hospitals. The main question was whether lipid emulsions are readily available and if published guidelines contributed to this availability. Additionally, we asked whether local anesthetic toxicity had already successfully been treated by lipid emulsions and what type of symptoms were treated. Results We received replies from n = 509 (39 %) hospitals. In 338 (66 %) of the responding hospitals, lipid emulsions are readily available. Hospitals with standard operating procedures (SOPs) implemented according to published guidelines have lipids significantly more often immediately available than hospitals with just SOPs (chi-square test of independence, p -value < 0.01). Of all responding hospitals 287 (56 %) have implemented a SOP for the treatment of toxic reactions to local anesthetics and 196 (39 %) of the hospitals introduced the SOP because of the guidelines. In 28 (6 %) of the hospitals, local anesthetic toxicity had already caused cardiac arrest with subsequent cardiopulmonary resuscitation in at least one patient. In 132 (26 %) hospitals, local anesthetic toxicity had already been treated by infusing lipid emulsions. Of these hospitals 128 (96 %) state this therapeutic approach was successful. Treatment with lipid emulsions was performed frequently after prodromal symptoms 83 (63 %) were witnessed. Conclusions The majority of surveyed German hospitals are prepared to treat toxic reactions to local anesthetics and published guidelines contributed to this preparedness. The infusion of lipid emulsions is a promising measure to deal with toxic reactions to local anesthetics. Since toxic reactions to local anesthetics are potentially lethal, it seems desirable that lipid emulsions are generally available in routine clinical practice. Currently, the treatment of toxic reactions to local anesthetics is mostly performed in situations (e. g. treatment of prodromal symptoms) that are not recommended by current guidelines. Further research is necessary to better define the future use of lipid emulsions in routine clinical practice.

INTRODUCTION:Patients with fibromyalgia syndrome (FMS) generally present with chronic widespread pain, accompanied by a range of additional and non-specific symptoms, such as fatigue, disturbed sleep, and cognitive dysfunction, which tend to increase with overall severity. Previous studies have shown moderate cognitive impairment in patients with FMS, but there are few valid data explicitly assessing the relevance of these findings to everyday functions, such as driving ability. Therefore, we studied patients with FMS to assess the impact of FMS on tests that predict driving ability.METHODS:Female patients with FMS were prospectively compared to a historical control group of healthy volunteers. The test battery comprised assessments of visual orientation, concentration, attention, vigilance, motor coordination, performance under stress, and reaction time.RESULTS:A total of 43 patients were matched to 129 controls. The results indicated that the patients' psychomotor and cognitive performances were significantly non-inferior when compared to healthy controls (with 0.05% alcohol), with the exception of motor coordination. Patients and healthy controls showed an age-related decline in test performance. Correlations were smaller in patients and reversed for vigilance which was linked to a greater FMS symptom load in younger patients.CONCLUSION:The results of the present study demonstrate that, in general, the driving ability of patients with FMS was not inferior to that of healthy volunteers based on a standardized computer-based test battery. However, variables, such as younger age, depression, anxiety, fatigue, pain, and poor motor coordination, likely contribute to the subjective perception of cognitive dysfunction in FMS.

UNLABELLED:Antidepressant drugs are commonly used to treat fibromyalgia, but there is little knowledge about their mechanisms of action. The aim of this study was to compare the cerebral and behavioral response to positive treatment effects of antidepressants or placebo. Ninety-two fibromyalgia patients participated in a 12-week, double-blind, placebo-controlled clinical trial with milnacipran, a serotonin-norepinephrine reuptake inhibitor. Before and after treatment, measures of cerebral pain processing were obtained using functional magnetic resonance imaging. Also, there were stimulus response assessments of pressure pain, measures of weekly pain, and fibromyalgia impact. Following treatment, milnacipran responders exhibited significantly higher activity in the posterior cingulum compared with placebo responders. The mere exposure to milnacipran did not explain our findings because milnacipran responders exhibited increased activity also in comparison to milnacipran nonresponders. Stimulus response assessments revealed specific antihyperalgesic effects in milnacipran responders, which was also correlated with reduced clinical pain and with increased activation of the posterior cingulum. A short history of pain predicted positive treatment response to milnacipran. We report segregated neural mechanisms for positive responses to treatment with milnacipran and placebo, reflected in the posterior cingulum. The increase of pain-evoked activation in the posterior cingulum may reflect a normalization of altered default mode network processing, an alteration implicated in fibromyalgia pathophysiology. PERSPECTIVE:This study presents neural and psychophysical correlates to positive treatment responses in patients with fibromyalgia, treated with either milnacipran or placebo. The comparison between placebo responders and milnacipran responders may shed light on the specific mechanisms involved in antidepressant treatment of chronic pain.

Aim: The inflammatory response following tissue injury after major surgery is known to affect endothelial function and vascular reactivity. In this study we evaluated the utility of bedside Digital Thermal Monitoring (DTM) as a surrogate for evaluating vascular function in the postoperative period.Methods: Ischemia-induced reactive hyperemia variables were measured in sixty patients scheduled for major thoracic surgery using DTM (VENDYS 5000BC; Endothelix, Inc., Houston, TX, USA) at baseline and at 24, 48, 72 hours, and day 5 postoperatively. Furthermore, baseline DTM variables (TR, aTR and AUCTR) and postoperative kinetics of these variables were compared among patients with and without preoperative chemo-radiation and cardiovascular risk factors.Results: There were no significant differences in the DTM parameters measured at baseline and on each of the studied postoperative days. Compared to the baseline, the lowest measures of all variables were observed 24 hrs postoperatively and the highest measures of all variables were observed at 72 hrs. Patients with abdominal obesity and smoking had lower DTM values than the rest of the study group.Conclusions: In our study, DTM as measured by the VENDYS 5000BC DTM system (Endothelix, Inc.) did not reveal significant changes in ischemia-induced reactive hyperemia (vascular reactivity) between the baseline and after surgery in the postoperative period. Patients with certain cardiovascular risk factors (abdominal obesity, smoking) had a significant lower DTM signal. Whether this novel non-invasive technique is able to serve as a perioperative diagnostic tool for patients in a clinical setting warrants further study.

BACKGROUND:Perioperative vascular function has been widely studied using noninvasive techniques that measure reactive hyperemia as a surrogate marker of vascular function. However, studies are limited to a static setting with patients tested at rest. We hypothesized that exercise would increase reactive hyperemia as measured by digital thermal monitoring (DTM) in association to patients' cardiometabolic risk.METHODS:Thirty patients (58 ± 9 years) scheduled for noncardiac surgery were studied prospectively. Preoperatively, temperature rebound (TR) following upper arm cuff occlusion was measured before and 10 minutes after exercise. Data are presented as means ± SD. Statistical analysis utilized ANOVA and Fisher's exact test, with P values <0.05 regarded as significant.RESULTS:Following exercise, TR-derived parameters increased significantly (absolute: 0.53 ± 0.95 versus 0.04 ± 0.42°C, P=0.04, and % change: 1.78 ± 3.29 versus 0.14 ± 1.27 %, P=0.03). All patients with preoperative cardiac risk factors had a change in TR (after/before exercise, ΔTR) with values falling in the lower two tertiles of the study population (ΔTR <1.1%).CONCLUSION:Exercise increased the reactive hyperemic response to ischemia. This dynamic response was blunted in patients with cardiac risk factors. The usability of this short-term effect for the preoperative assessment of endothelial function warrants further study.

ObjectiveThere is vast evidence to support the presence of brain aberrations in patients with fibromyalgia (FM), and it is possible that central plasticity is critical for the transition from acute to chronic pain. The aim of the present study was to investigate the relationship between brain structure and function in patients with FM.MethodsFunctional connectivity of the brain during application of intermittent pressure-pain stimuli and measures of brain structure were compared between 26 patients with FM and 13 age- and sex-matched healthy controls. Magnetic resonance imaging (MRI) was performed to obtain high-resolution anatomic images and functional MRI scans of the brain, which were used for measurements of pain-evoked brain activity.ResultsFM patients displayed a distinct overlap between decreased cortical thickness, decreased brain volumes, and decreased functional regional coherence in the rostral anterior cingulate cortex. The morphometric changes were more pronounced with longer exposure to FM pain. In addition, there was evidence of an association between structural and functional changes in the mesolimbic areas of the brain and the severity of comorbid depression symptoms in FM patients.ConclusionThe combined integration of structural and functional measures allowed for a unique characterization of the impact of FM pain on the brain. These data may lead to the identification of early structural and functional brain alterations in response to pain, which could be used to develop markers for predicting the development of FM and other pain disorders.

Das schwere Schädel-Hirn-Trauma (SHT) gehört zu den häufigsten Todesursachen bei jungen Erwachsenen. Beim schweren SHT folgt der primären Verletzung in der Regel eine ausgeprägte pathophysiologische Kaskade, die Sekundärschäden anrichtet und für eine Vielzahl der Todesfälle verantwortlich ist. Ziel der intensivmedizinischen Therapie nach SHT ist es u. a., die Ausprägung und die damit einhergehenden Komplikationen zu kontrollieren. Von besonderer Bedeutung sind dabei das strikte Vermeiden von Hypoxämie, arterieller Hypotension, intrakranieller Hypertension, Hyperthermie, Hyperglykämie, Hypoglykämie und thrombembolischen Ereignissen. Eine weitere Möglichkeit, den Verlauf bzw. das Ausmaß eines SHT günstig zu beeinflussen, ergibt sich aus dem bis dato vergleichsweise wenig beachteten intensivmedizinischen Aspekt der Ernährung von Intensivpatienten nach SHT. Innerhalb von 24 h sollte bei diesen Patienten mit der Ernährung begonnen werden. Generell sollte, wenn möglich, einer enteralen Ernährung der Vorzug gegeben werden. Die volle enterale Verabreichung des errechneten Energiebedarfs vom ersten Tag nach Trauma, wenn möglich, kann dazu beitragen, die Infektions- und allgemeine Komplikationsrate signifikant zu senken. In der vorliegenden Arbeit soll der Stellenwert der Ernährung bei der Therapie des SHT betrachtet werden.

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24 h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.

There is evidence for augmented processing of pain and impaired endogenous pain inhibition in Fibromyalgia syndrome (FM). In order to fully understand the mechanisms involved in FM pathology, there is a need for closer investigation of endogenous pain modulation. In the present study, we compared the functional connectivity of the descending pain inhibitory network in age-matched FM patients and healthy controls (HC).

Background. Brachial artery reactivity testing (BART)-a surrogate test of microvascular function-predicts cardiac risk in the nonsurgical population and associates it with adverse outcome after vascular surgery. This pilot study investigated BART-derived variables, including flow-mediated dilation (FMD), in preoperative risk stratification for major thoracic surgery.Methods. After institutional review board approval, BART was performed in 63 patients before major thoracic surgery. Ultrasonography recorded two-dimensional images and Doppler flow signals of the brachial artery preoperatively at baseline and after induced reactive hyperemia. Variables derived using BART were correlated with preoperative risk factors, established risk scores, and postoperative complications.Results. The median preoperative FMD value in patients without postoperative complications was 11.5%. This value was used to delineate all patients into two groups: low (FMD < 11.5%) and high (FMD >= 11.5%) FMD cohorts. Patients in the low FMD group experienced more postoperative complications: 54% versus 30% had one or more adverse postoperative event, and 11% versus 0% had three or more adverse postoperative events (p < 0.001), respectively. The low FMD group required longer intensive care unit (3.9 +/- 2.0 days versus 0.9 +/- 0.3 days; p = 0.015) and hospital (14.0 +/- 3.3 days versus 6.8 +/- 0.6 days; p = 0.007) stays. This cutoff point for FMD accurately predicted 71% of the patients with adverse postoperative events, achieving 71.4% (95% confidence interval, 54.7 to 88.2) sensitivity and 48.6% (95% confidence interval, 32.0 to 65.1) specificity.Conclusions. Using BART, preoperative microvascular dysfunction can be identified in patients at increased risk for postoperative complications. These data suggest that larger observational studies and studies exploring preoperative optimization strategies aimed at improving microvascular function are warranted.

BACKGROUND:The need for a cesarean delivery may interfere negatively with the overall experience of childbirth. Several factors related to anesthesiological management such as postoperative pain and discomfort, nausea and pruritus, and postdural puncture headache (PDPH), may lead to dissatisfaction and have a negative impact on early mobilization and a new mother's ability to care for her newborn baby. Optimal prophylaxis and treatment decrease these complications, increase satisfaction, and prevent chronic pain. This survey determined how prophylaxis and treatment of pain, PDPH, nausea, and pruritus after cesarean section (CS) is managed.METHODS:A questionnaire was sent to 709 departments of anesthesiology serving an obstetric unit in Germany. The questionnaire asked about different aspects of pain management, the management of accidental dural puncture (ADP), and treatment of PDPH. Further we asked about therapy and prophylaxis of nausea and pruritus in the peripartal setting.RESULTS:In all, 360 questionnaires (50.8%) were returned; 346 were complete and analyzed (accounting for 330000 births per year). Paracetamol (77.5%) and piritramide (85.6%) are the most common analgesics used. If epidural catheters were used for anesthesia for CS, 47.7% were used for postoperative pain therapy. However, 92.7% of the departments removed catheters in less than 24 hours after delivery. In case of an ADP most departments (69.9%) repeated puncture, 2.6% placed catheters intrathecally. Median blood volume for an epidural blood patch was 10ml.CONCLUSION:Apart from conservative treatment of PDPH, prophylaxis and treatment of pain after cesarean delivery, PDPH, nausea, and pruritus varied widely, indicating the need for the qualitative evaluation of overall management.

BACKGROUND:The rate of Caesarean sections in Germany continues to rise. The change in anesthetic technique of choice from general to spinal anesthesia began later than in other countries and at the last survey in 2002 was not widely established. The literature on the anesthetic management of Caesarean sections contains many controversies, for example fluid preload before performing spinal anesthesia and the vasopressor of choice. Other issues have received relatively little attention, such as the level of experience of anesthesiologists working autonomously on the labour ward or the timing of antibiotic prophylaxis. The aim of the current survey was to provide an updated overview of anesthetic management of Caesarean sections in Germany.MATERIAL AND METHODS:A questionnaire was sent out to 709 departments of anesthesiology serving obstetric units in Germany. The questionnaire concerned various aspects of anesthetic management of Caesarean sections.RESULTS:A total of 360 questionnaires (50.8%) were returned of which 346 were complete and could be analyzed, accounting for 330,000 births and 90,000 Caesarean sections per year. The predominant anesthetic method used for Caesarean sections was spinal anesthesia (90.8%) using hyperbaric bupivacaine and in approximately one third of the hospitals surveyed without administering intrathecal opioids. Approximately 12% of the departments surveyed used traumatic Quincke needles. In 86.2% the vasopressor of choice was caffedrine/theodrenaline. Nitrous oxide was used in only 19.2% of departments surveyed when general anesthesia is performed. An antibiotic drug was administered in only 11% of hospitals before cord clamping. In 43.1% no neonatologist was available to treat unexpected critically ill newborns. In 32.1% of departments surveyed residents with less than 2 years experience worked autonomously on the labour ward.CONCLUSIONS:Currently the predominant anesthetic technique of choice in Germany is spinal anaesthesia and at a much higher rate than in 2002. In addition 12% of departments use traumatic Quincke needles which are associated with a higher incidence of postpuncture headache. Nitrous oxide is no longer frequently used in Germany. Finally, the administration of an antibiotic before cord clamping has been shown to lead to lower rates of endometritis and postoperative wound infection without detrimental effects on the newborn. This is practiced in only a small minority of departments across Germany.

OBJECTIVE:Mood disturbance is common among patients with fibromyalgia (FM), but the influence of psychological symptoms on pain processing in this disorder is unknown. We undertook the present study to investigate the differential effect of depressive symptoms, anxiety, and catastrophizing on 1) pain symptoms and subjective ratings of general health status and 2) sensitivity to pain and cerebral processing of pressure pain.METHODS:Eighty-three women (mean ± SD age 43.8 ± 8.1 years) who fulfilled the American College of Rheumatology 1990 criteria for the classification of FM participated in the study. Patients rated pain intensity (100-mm visual analog scale [VAS]), severity of FM (Fibromyalgia Impact Questionnaire), general health status (Short Form 36), depressive symptoms (Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), and catastrophizing (Coping Strategies Questionnaire). Experimental pain in the thumb was induced using a computer-controlled pressure stimulator. Event-related functional magnetic resonance imaging was performed during administration of painful stimuli representing 50 mm on a pain VAS, as well as nonpainful pressures.RESULTS:A correlation analysis including all self-ratings showed that depressive symptoms, anxiety, and catastrophizing scores were correlated with one another (P < 0.001), but did not correlate with ratings of clinical pain or with sensitivity to pressure pain. However, the subjective rating of general health was correlated with depressive symptoms and anxiety (P < 0.001). Analyses of imaging results using self-rated psychological measures as covariates showed that brain activity during experimental pain was not modulated by depressive symptoms, anxiety, or catastrophizing.CONCLUSION:Negative mood in FM patients can lead to a poor perception of one's physical health (and vice versa) but does not influence performance on assessments of clinical and experimental pain. Our data provide evidence that 2 partially segregated mechanisms are involved in the neural processing of experimental pain and negative affect.