Since the last surveys on the utilization of muscle relaxants in general anesthesia in 2000 and 2005, it can be assumed that the introduction of sugammadex for the rapid and safe reversal of neuromuscular blocks as well as the establishment of new surgical techniques, have had an impact on the use of muscle relaxants in general anesthesia. A web-based questionnaire was used to survey anesthesia departments and outpatient surgery centers regarding the use of neuromuscular blocking agents. The aim was a comparison with previous surveys and the statistical analysis was descriptive. The response rate of the 1027 anesthesia departments contacted was 16.5%. The availability of neuromuscular monitoring in hospitals continues to improve. The most frequently used drug for rapid sequence induction is now rocuronium rather than succinylcholine. Sugammadex is now available as a drug in 86% of the responding anesthesia departments. The concept of complete relaxation for laparoscopic surgery called deep block is used by 60% of those surveyed. The results are analyzed and discussed in the context of the first European guidelines published in 2023 by the European Society of Anaesthesiology and Intensive Care (ESAIC). They show that with respect to the use of succinylcholine and the support by new surgical techniques have changed the management of neuromuscular block since the last surveys. The use of neuromuscular monitoring to control the management of muscle relaxation is still not standard in all hospitals, so that an additional patient risk cannot be ruled out.

Seit den letzten Umfragen zu den Anwendungsgewohnheiten der Muskelrelaxanzien im Rahmen einer Allgemeinanästhesie ist anzunehmen, dass die Einführung von Sugammadex zur Reversierung der neuromuskulären Blockade, aber auch die Etablierung neuer Operationstechniken die anästhesiologischen Anwendungsgewohnheiten verändert haben. Mittels webbasiertem Fragebogen wurden anästhesiologische Kliniken und Abteilungen ambulanter OP-Zentren hinsichtlich der Anwendungsgewohnheiten der neuromuskulären Blockade befragt. Vergleiche mit den vorbestehenden Umfragen waren angestrebt; die statistische Analyse erfolgte deskriptiv. Die Rücklaufquote der insgesamt 1027 angefragten Anästhesieabteilungen betrug 16,5

INTRODUCTION:Data concerning anaesthesia for endourology are rare, and options for it are numerous. Thus, identifying the optimal anaesthesia regimen remains challenging. With this study we aimed to provide the means for selecting optimal anaesthesia for endourology procedures. MATERIAL AND METHODS:This was a randomised, open-label, controlled study conducted in a single tertiary hospital. Inclusion criteria: American Society of Anesthesiologists (ASA) physical status/risk category I-III, and scheduled surgery time < 60 minutes. Exclusion criteria: contraindications or lack of consent for one of the anaesthesia types, intellectual disabilities, pregnancy, breastfeeding, and refusal to participate. The participants were divided into 3 groups: G1, spinal anaesthesia (SPA) with bupivacaine; G2, SPA with prilocaine; G3, total intravenous anaesthesia (TIVA) with remifentanil and propofol. The primary outcome measure was time to ambulation, while the secondary outcome measures included perioperative hypotension. The results are presented as mean ± SD or median [IQR]. RESULTS:In total, 117 patients completed the study. The time to ambulation (minutes) was significantly different between all groups: 187.95 ± 49.82, 161.05 ± 46.28, and 129.14 ± 63.75 min, for G1, G2 and G3, respectively. The mean arterial pressure drop from baseline during the procedure was most pronounced in G3 (35% [30-44], P < 0.001) and lowest in G2 (18% [12-27], P < 0.001 vs. G3, NS vs. bupivacaine). Machine-learning models were trained and demonstrated satisfactory performance in predicting the time spent in recovery. CONCLUSIONS:In the context of endourological surgery, the time required for ambulation was shortest when using TIVA, while SPA with hyperbaric prilocaine provides the closest approximation to optimal anaesthesia.

AbstractObjectiveThe course of sedation during drug‐induced sleep endoscopy (DISE) depends on the application pattern of the sedative drug. The depth of sedation should imitate light and deep sleep as well. Moreover, there should be as many breathing cycles as possible available for observation during light and deep sedation. The aim of the study was to evaluate different rates of propofol application with respect to the achieved depth and length of the course of sedation.MethodsSixty‐three consecutive patients with obstructive sleep apnea and/or snoring undergoing DISE were randomly sedated by propofol perfusion at seven different application patterns: 14, 16, 18, 19, 20, 22 mg/kg/h (0.233, 0.267, 0.3, 0.317, 0.333, 0.367 mg/kg/min) per perfusor and individual bolus application 10 mg each. Sedation depth was monitored by BiSpectral Index™ (BIS). The influence of baseline parameters and the courses of sedation were analyzed.ResultsThe application rate was the only factor that influenced the depth of sedation. Basic parameters (gender, age, body mass index, apnea‐hypopnea index) had no influence on the depth of sedation. The sedation depth was dependent on the rate of propofol application. Regimes at 14 and 16 mg/kg/h as well as bolus application did not reach BIS levels below 50 representing deep sleep. Propofol doses of more than 20 mg/kg/h led to rapid decreases of sedation levels below deep sleep niveau. Propofol rates between 18 and 20 mg/kg/h enable BIS levels below 50 representing deep sleep and providing enough breathing cycles for observation.ConclusionLower application rates of propofol provide slower courses of sedation and shallower depths of sedation. A rate of 14 mg/kg/h might be appropriate to reach a sedation plateau at light sleep. A rate of 18 mg/kg/h leads to a sedation, corresponding to deep sleep. The combination of both rates might be a suitable pattern for performing sedation‐controlled DISE.Level of evidence2: Randomized trial.

Background: Volatile anesthetics are becoming increasingly used for sedation in ICU but the evidence for long-term use is still low. We conducted a randomized controlled trial comparing sevoflurane with intravenous sedation with particular focus on efficacy and safety. Methods: In this prospective, randomized-controlled phase-IIb monocentric clinical trial ICU patients requiring at least 48h of sedation were randomized to receive sevoflurane (S) or propofol (P). Sedation quality was controlled using the Richmond Agitation Sedation Scale. Following termination of sedation, time to spontaneous breathing or extubation and opioid consumption, hemodynamics, ICU and hospital length of stay (LOS) as well as adverse events were recorded.Results: 79 patients were eligible to randomization. Use of sevoflurane (n=39) was associated with comparable sedation quality as use of propofol (n=40) and resulted in shortened times to spontaneous breathing (26min vs. 375min, P<0.001). Patients sedated with propofol had lower opioid requirements (remifentanil:400µg/h vs. 500µg/h, P=0.007 and sufentanil:40µg/h vs. 30µg/h, P=0.007) while hemodynamics, LOS or the occurrence of adverse events did not differ.Conclusion: Long-term sedated ICU patients under use of sevoflurane awaken more quickly and exhibit comparable sedation quality as patients sedated with propofol. Use of sevoflurane for long-term sedation is safe and non-inferior compared to use of propofol in ICU.

PURPOSE:To compare ICU-free (ICU-FD) and ventilator-free days (VFD) in the 30 days after randomization in patients that received isoflurane or propofol without receiving the other sedative.MATERIALS AND METHODS:A recent randomized controlled trial (RCT) compared inhaled isoflurane via the Sedaconda® anaesthetic conserving device (ACD) with intravenous propofol for up to 54 h (Meiser et al. 2021). After end of study treatment, continued sedation was locally determined. Patients were eligible for this post-hoc analysis only if they had available 30-day follow-up data and never converted to the other drug in the 30 days from randomization. Data on ventilator use, ICU stay, concomitant sedative use, renal replacement therapy (RRT) and mortality were collected.RESULTS:Sixty-nine of 150 patients randomized to isoflurane and 109 of 151 patients randomized to propofol were eligible. After adjusting for potential confounders, the isoflurane group had more ICU-FD than the propofol group (17.3 vs 13.8 days, p = 0.028). VFD for the isoflurane and propofol groups were 19.8 and 18.5 respectively (p = 0.454). Other sedatives were used more frequently (p < 0.0001) and RRT started in a greater proportion of patients in the propofol group (p = 0.011).CONCLUSIONS:Isoflurane via the ACD was not associated with more VFD but with more ICU-FD and less concomitant sedative use.

We present 2 cases of severe Covid-19 with comorbidities (arterial hypertension, obesity, diabetes mellitus) treated with membrane-based therapeutic plasma exchanges in combination with a short-term high-dose immunosuppressive therapy. The therapy has been initiated in an attempt to alleviate the prevalent cytokine storm and to prevent intubation and invasive mechanical ventilation, when a long-term nasal oxygen therapy with a maximum flow rate of 8L/min was insufficient to achieve an adequate oxygenation. Even though patient 2 had to be intubated after the 4th cycle of plasmapheresis due to the exhaustion of the respiratory muscles and the subsequent acquired sepsis with a microbiological evidence of a mixed bacterial-fungal infection, both patients showed a good response to treatment, including improvement of laboratory and radiological findings. To our knowledge, this combination of therapeutic plasma exchange with a high-dose steroid therapy has not been reported previously.

Introduction Metformin-associated lactic acidosis (MALA) is a rare but life-threatening condition. Here, we report the outcome of a patient with MALA complicated by acute coronary syndrome. Case presentation A 47-year-old obese woman of Caucasian ethnicity was admitted for syncope and tachypnea with Kussmaul breathing. She had a type-2 diabetes and was on oral antidiabetic therapy. Hemoglobin A1c was 6.6%. On admission, a severe acute kidney injury (serum creatinine: 1251 µmol/L) with hyperkalemia (7.5 mmol/L) and severe lactic acidosis (ph:7.042, bicarbonate: 9.9 mmol/L, partial pressure of carbon dioxide: 21.8 mmHg, lactate: 20.0 mmol/L) was found. Despite bicarbonate therapy, ph further decreased. Within 2.5 h of admission, a temporary hemodialysis catheter was placed, and one session of a high-efficiency hemodialysis was performed. 8 h after admission, a continuous venovenous hemodiafiltration was initiated and maintained for 2 days. The metformin therapy was stopped. Supplemental oxygen, intravenous catecholamines (4 days) and antibiotic therapy (7 days) were applied. During this therapy of lactic acidosis, an acute coronary syndrome evolved by day 2 after admission and resolved by day 5 in hospital. After recovery, the patient was transferred to a general ward on day 7 and left the hospital on day 11. By discharge, both the acute kidney injury and the acute coronary syndrome were reversible. Conclusion In the patient with MALA complicated by acute coronary syndrome, the combination of a high-efficiency hemodialysis and, consecutively, continuous venovenous hemodiafiltration led to a favorable outcome.

The aim of the current paper is to summarize the results of the International CytoSorb Registry. Data were collected on patients of the intensive care unit. The primary endpoint was actual in-hospital mortality compared to the mortality predicted by APACHE II score. The main secondary endpoints were SOFA scores, inflammatory biomarkers and overall evaluation of the general condition. 1434 patients were enrolled. Indications for hemoadsorption were sepsis/septic shock (N = 936); cardiac surgery perioperatively (N = 172); cardiac surgery postoperatively (N = 67) and "other" reasons (N = 259). APACHE-II-predicted mortality was 62.0±24.8%, whereas observed hospital mortality was 50.1%. Overall SOFA scores did not change but cardiovascular and pulmonary SOFA scores decreased by 0.4 [-0.5;-0.3] and -0.2 [-0.3;-0.2] points, respectively. Serum procalcitonin and C-reactive protein levels showed significant reduction: -15.4 [-19.6;-11.17] ng/mL; -17,52 [-70;44] mg/L, respectively. In the septic cohort PCT and IL-6 also showed significant reduction: -18.2 [-23.6;-12.8] ng/mL; -2.6 [-3.0;-2.2] pg/mL, respectively. Evaluation of the overall effect: minimal improvement (22%), much improvement (22%) and very much improvement (10%), no change observed (30%) and deterioration (4%). There was no significant difference in the primary outcome of mortality, but there were improvements in cardiovascular and pulmonary SOFA scores and a reduction in PCT, CRP and IL-6 levels. Trial registration: ClinicalTrials.gov Identifier: NCT02312024 (retrospectively registered).

BACKGROUND:Previous studies indicate that isoflurane could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies evaluating isoflurane's efficacy have been small. The aim of this study was to test whether the sedation with isoflurane was non-inferior to sedation with propofol. METHODS:This phase 3, randomised, controlled, open-label non-inferiority trial evaluated the efficacy and safety of up to 54 h of isoflurane compared with propofol in adults (aged ≥18 years) who were invasively ventilated in ICUs in Germany (21 sites) and Slovenia (three sites). Patients were randomly assigned (1:1) to isoflurane inhalation via the Sedaconda anaesthetic conserving device (ACD; Sedana Medical AB, Danderyd, Sweden; ACD-L [dead space 100 mL] or ACD-S [dead space 50 mL]) or intravenous propofol infusion (20 mg/mL) for 48 h (range 42-54) using permuted block randomisation with a centralised electronic randomisation system. The primary endpoint was percentage of time in Richmond Agitation-Sedation Scale (RASS) range -1 to -4, assessed in eligible participants with at least 12 h sedation (the per-protocol population), five or more RASS measurements, and no major protocol violations, with a non-inferiority margin of 15%. Key secondary endpoints were opioid requirements, spontaneous breathing, time to wake-up and extubation, and adverse events. Safety was assessed in all patients who received at least one dose. The trial is complete and registered with EudraCT, 2016-004551-67. FINDINGS:Between July 2, 2017, and Jan 12, 2020, 338 patients were enrolled and 301 (89%) were randomly assigned to isoflurane (n=150) or propofol (n=151). 146 patients (97%) in each group completed the 24-h follow-up. 146 (97%) patients in the isoflurane group and 148 (98%) of patients in the propofol group were included in the per-protocol analysis of the primary endpoint. Least-squares mean percentage of time in RASS target range was 90·7% (95% CI 86·8-94·6) for isoflurane and 91·1% (87·2-95·1) for propofol. With isoflurane sedation, opioid dose intensity was 29% lower than with propofol for the overall sedation period (0·22 [0·12-0·34] vs 0·32 [0·21-0·42] mg/kg per h morphine equivalent dose, p=0·0036) and spontaneous breathing was more frequent on day 1 (odds ratio [OR] 1·72 [1·12-2·64], generalised mixed linear model p=0·013, with estimated rates of 50% of observations with isoflurane vs 37% with propofol). Extubation times were short and median wake-up was significantly faster after isoflurane on day 2 (20 min [IQR 10-30] vs 30 min [11-120]; Cox regression p=0·0011). The most common adverse events by treatment group (isoflurane vs propofol) were: hypertension (ten [7%] of 150 vs two [1%] of 151), delirium (eight [5%] vs seven [5%]), oliguria (seven [5%] vs six [4%]), and atrial fibrillation (five [3%] vs four [3%]). INTERPRETATION:These results support the use of isoflurane in invasively ventilated patients who have a clinical need for sedation. FUNDING:Sedana Medical AB.

Background: Small studies indicate that isoflurane may be useful for sedation during invasive ventilation of ICU patients. There are no published large prospective efficacy trials. Methods: This phase 3, non-inferiority trial evaluated the efficacy and safety of ≤54 hours of isoflurane via the anaesthetic conserving device (ACD) compared with propofol in invasively ventilated ICU patients (30-day follow-up). Primary endpoint was percentage of time in Richmond Agitation–Sedation Scale (RASS) range –1 to –4; the predefined non-inferiority margin was 15% below the propofol mean. Secondary endpoints: opioid requirements, spontaneous breathing during sedation, time to wake-up and extubation, adverse events, ventilator-, ICU-, coma- and delirium-free days, and 30-day mortality. Findings: 301 patients were randomized to isoflurane (n=150) or propofol (n=151). Least-squares mean percentage of time (95% CI) in RASS target range was 90·7% (86·8–94·6) for isoflurane and 91·1% (87·2–95·0) for propofol. With isoflurane, opioid requirements were reduced by 29% (ANOVA, p=0·004) throughout and spontaneous breathing more frequent on Day 1 (50·3% vs 37·0%, GLMM, p=0·013). Extubation and wake-up times were short, and wake-up time was significantly shorter after isoflurane on Day 2 (median [IQR]: 20 [10–30] vs 30 [11–120] minutes; Cox regression p=0·001). No significant differences in serious adverse events, ventilator-, ICU-, coma- and delirium-free days or mortality. Interpretation: Isoflurane via the ACD for sedation of ICU patients was efficacious, non-inferior to propofol, with lower opioid use, more spontaneous breathing, and shorter wake-up time. Trial Registration: EudraCT#: 2016-004551-67Funding . This study was funded by Sedana Medical AB. Funding: This study was funded by Sedana Medical AB. Declaration of Interest: AM: Consultancy fees: Sedana Medical AB. TV: Grant support: B Braun. UG: Lecture fees: MT Monitor Technik, Getinge; reimbursement of clinical study expenses: Bayer Healthcare. TB: Lecture fees and travel costs: Sedana, Lowenstein Medical, Drager Medical. PK: Personal fees: Sedana Medical AB. MD: Lecture fees and travel costs: Cytosorbents Europe GmbH. PS: Employee and shareholder: Sedana Medical AB. JW, HB, KS, RK, AF, SCT, JS, HV, MB: Nothing to declare. Ethical Approval: The study was conducted in accordance with International Conference on Harmonisation Good Clinical Practice standards and the Declaration of Helsinki. Ethical approval for this study was provided by the ethics committees in Germany (Ethikkommission der Arztekammer des Saarlandes

Background: Our aim is to report the results of the ‘liver indication’ subset of patients in the CytoSorb International Registry. Methods: Structured data were recorded. Treatment characteristics and changes from T1 (start of hemoadsorption) to T2 (termination) were evaluated with a special focus on bilirubin, C-reactive protein, procalcitonin, interleukin-6, platelet levels, SOFA scores, mortality, and subjective assessment by the attending physicians. Results: Until January 2021, from the total 1434 patients, 109 (age: 49.2 ± 17.1 years, 57.8% males) received treatment for hyperbilirubinemia. APACHE II-predicted mortality was 49.6 ± 26.8%. In the study, 91% of patients were alive at the termination of hemoadsorption and improvement was observed by the physicians in 75 cases. Overall, 65 (59.6%) patients died in the hospital, and 60 (55.0%) died in the ICU. Patients received a median of two treatments for a median of 43 h (interquartile range: 24–72 h) in total. Serum bilirubin levels reduced significantly to −4.6 (95% CI: −6.329 to −2.8) mg/dL. Thrombocytopenia was reported in four patients as an adverse event. Conclusions: We report the largest case series on hemoadsorption for ‘liver indication’ from the CytoSorb International Registry. The finding of significant bilirubin removal observed in our study could have substantial impact in designing and executing further studies on the effects of hemoadsorption in liver dysfunction, which are certainly warranted.

Background The course of sedation during drug induced sleep endoscopy (DISE) depends on the application pattern of the sedative drug. In order to perform a good evaluation of the upper airway a long transitional period between superficial and deep sedation, providing enough time of investigation, needs to be available. Up to now only few data are present on dose dependent drug application during DISE.

Hintergrund Der Verlauf der Sedierung bei der Medikamenten induzierten Schlafendoskopie (MISE) ist abhängig von der Applikationsweise des Sedativums. Wichtig für eine suffiziente Evaluation der oberen Atemwege ist eine langsame Übergangsphase zwischen leichter und starker Sedierung um ausreichend Beobachtungszeit zur Verfügung zu haben. Zur adäquaten Propofolapplikation liegen nur wenige Daten für die MISE vor.

Background Haemoadsorption has been described as an effective way to control increased pro- and anti-inflammatory mediators (“cytokine storm”) in septic shock patients. No prospective or randomised clinical study has yet confirmed these results. However, no study has yet prospectively specifically investigated patients in severe septic shock with sepsis-associated acute kidney injury (SA-AKI). Therefore, we aimed to examine whether haemoadsorption could influence intensive care unit (ICU) and hospital mortality in these patients. Furthermore, we examined the influence of haemoadsorption on length of stay in the ICU and therapeutic support. Methods Retrospective control group and prospective intervention group design in a tertiary hospital in central Europe (Germany). Intervention was the implementation of haemoadsorption for patients in septic shock with SA-AKI. 76 patients were included in this analysis. Results Severity of illness as depicted by APACHE II was higher in patients treated with haemoadsorption. Risk-adjusted ICU mortality rates (O/E ratios) did not differ significantly between the groups (0.80 vs. 0.83). We observed in patients treated with haemoadsorption a shorter LOS and shorter therapeutic support such as catecholamine dependency and duration of RRT. However, in multivariate analysis (logistic regression for mortality, competing risk for LOS), we found no significant differences between the two groups. Conclusions The implementation of haemoadsorption for patients in septic shock with acute renal failure did not lead to a reduction in ICU or hospital mortality rates. Despite univariate analysis delivering some evidence for a shorter duration of ICU-related treatments in the haemoadsorption group, these results did not remain significant in multivariate analysis. Trial registration CytoSorb ® registry https://clinicaltrials.gov/ct2/show/NCT02312024 . December 9, 2014. Database: https://www.cytosorb-registry.org/ (registration for content acquisition is necessary)

„Wir bekommen einen Zugang aus der Notaufnahme – ein Kind, zwei Jahre alt, nach einem Verkehrsunfall …“ So oder ähnlich lauten die Worte, die Stress auslösen. Die meisten Kollegen hoffen, dass der Kelch an ihnen vorübergeht und sie nicht mit der Betreuung dieses Kindes beauftragt werden. In solchen Situationen erweisen sich digitale kognitive Hilfsmittel als wahre Retter in der Not.

Einleitung Die ambulant erworbene Pneumonie stellt die häufigste Infektionskrankheit in Europa dar. Sie geht häufig mit schweren Komplikationen einher und stellt einen medizinischen Notfall dar.

Background: To date, there are no significant comparative data concerning the knowledge of residents and board-certified anaesthesiologists in matters of multi-resistant pathogens (MRP) and intelligent antibiotic utilization. Methods: Between Jun. 2017 and Nov. 2017 a survey comprising 5 +50 items was carried out in 16 anaesthesiology departments and distributed according to the number of physicians working at each department. The impact of the educational level (residents vs. board-certified anaesthesiologists) on various predetermined endpoints was analysed by applying multivariable logistic regression models. Results: The return rate was 54% (684/1268). 40.4% of residents and 19% of anaesthesiologists (p<0.001) considered themselves to be uncertain or very uncertain in the interpretation of microbiological diagnostic results. Concerning the choice of adequate antibiotic drugs, 72.2% and 37.8% (p<0.001), respectively, reported precariousness; regarding the determination of dose, frequency, and duration of antibiotic prescription the respective figures were 69.1% and 36% (p<0,001). 83.6% and 50.6% (p<0.001), respectively, estimated their knowledge about Antibiotic Stewardship as completely lacking or little. Only 9.2% of the residents and 24.4% of the board-certified physicians (p<0.001) judged the hospital-intern educational activities regarding anti- infective treatment as sufficient. In both groups, 69.6% and 46.5% (p<0.001), respectively, had not participated in a qualifying training inside or outside the hospital during the previous twelve months. 85% in each group advocated the obligatory integration of teaching and learning content concerning anti-infective therapy in the German board certification of anaesthesiologists. Based on the multivariable models, residents estimated their own skills (certainty and knowledge) as being significantly worse and exhibited significantly less knowledge than board-certified anaesthesiologists. Conclusion: The number and content of continuous medical education activities as well the curriculum for board certification in anaesthesiology should be adapted to the increasing need for intelligent antibiotic utilization, which exists for anaesthesiology residents in daily clinical routine.