Die Einführung des Hybrid-OPs ist eine der innovativsten Entwicklungen im Bereich chirurgischer Behandlungsmethoden. Hybrid-OPs ermöglichen die Kombination minimalinvasiver Chirurgie mit interventionellen Verfahren unter Nutzung modernster Bildgebungstechnologien und werden somit für viele chirurgische Disziplinen in Zukunft von großem Interesse werden. Implikationen für das anästhesiologische Management sollen in diesem Artikel anhand von Herzklappenprozeduren vorgestellt werden.

Anhand einer Kasuistik wird die aktuelle S1-Leitlinie „Intraoperative klinische Anwendung von hämodynamischem Monitoring bei nichtkardiochirurgischen Patient:innen“ unter dem Aspekt eines optimierten intraoperativen anästhesiologischen Managements vorgestellt. Die S1-Leitlinie wurde erarbeitet unter der Zielsetzung, die für die tägliche klinische Praxis wichtigen Fragen zum intraoperativen hämodynamischen Monitoring und Management zu identifizieren, in einer Leitliniengruppe zu diskutieren und auf Basis des aktuellen Wissensstandes zu beantworten. Die Leitlinie wurde unter Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e. V. (DGAI) erarbeitet und bei der AWMF unter der Registriernummer 001/049 im September 2023 publiziert.

The development and implementation of the hybrid operating theatre over the last decade is one of the most innovative advancements in the field of medical interdisciplinary treatment options. The hybrid operating theatre allows the combination of minimally invasive surgery and interventional procedures using the benefits of modern imaging technologies. Therefore, it will be of increasing interest for different kinds of surgical disciplines in the future. In Germany, the hybrid operating theatre is mainly used in the field of transcatheter based heart valve procedures and in the field of vascular surgery cooperating with interventional radiology. Managing this special patient population is a highly challenging task for all players in this setting, especially for the cardiac surgeon, the cardiologist, and the anaesthesiologist. Only close interdisciplinary cooperation ensures optimal treatment. The impact of recent developments in the field of transcatheter based heart valve procedures on anaesthesia management will be addressed in this article.

Die Einfuhrung des Hybrid-OPs ist eine der innovativsten Entwicklungen im Bereich chirurgischer Behandlungsmethoden. Hybrid-OPs ermoglichen die Kombination minimalinvasiver Chirurgie mit interventionellen Verfahren unter Nutzung modernster Bildgebungstechnologien und werden somit fur viele chirurgische Disziplinen in Zukunft von gro ss em Interesse werden. Implikationen fur das anasthesiologische Management sollen in diesem Artikel anhand von Herzklappenprozeduren vorgestellt werden. Abstract The development and implementation of the hybrid operating theatre over the last decade is one of the most innovative advancements in the field of medical interdisciplinary treatment options. The hybrid operating theatre allows the combination of minimally invasive surgery and interventional procedures using the benefits of modern imaging technologies. Therefore, it will be of increasing interest for different kinds of surgical disciplines in the future. In Germany, the hybrid operating theatre is mainly used in the field of transcatheter based heart valve procedures and in the field of vascular surgery cooperating with interventional radiology. Managing this special patient population is a highly challenging task for all players in this setting, especially for the cardiac surgeon, the cardiologist, and the anaesthesiologist. Only close interdisciplinary cooperation ensures optimal treatment. The impact of recent developments in the field of transcatheter based heart valve procedures on anaesthesia management will be addressed in this article.

Background Oscillometric, non-invasive blood pressure measurement (NIBP) is the first choice of blood pressure monitoring in the majority of low and moderate risk surgeries. In patients with morbid obesity, however, it is subject to several limitations. The aim was to compare arterial pressure monitoring by NIBP and a non-invasive finger-cuff technology (Nexfin®) with the gold-standard invasive arterial pressure (IAP). Methods In this secondary analysis of a prospective observational, single centre cohort study, systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were measured at 16 defined perioperative time points including posture changes, fluid bolus administration and pneumoperitoneum (PP) in patients undergoing laparoscopic bariatric surgery. Absolute arterial pressures by NIBP, Nexfin® and IAP were compared using correlation and Bland Altman analyses. Interchangeability was defined by a mean difference ≤ 5 mmHg (SD ≤8 mmHg). Percentage error (PE) was calculated as an additional statistical estimate. For hemodynamic trending, concordance rates were analysed according to the Critchley criterion. Results Sixty patients (mean body mass index of 49.2 kg/m 2 ) were enrolled and data from 56 finally analysed. Pooled blood pressure values of all time points showed a significant positive correlation for both NIPB and Nexfin® versus IAP. Pooled PE for NIBP versus IAP was 37% (SAP), 35% (DAP) and 30% (MAP), for Nexfin versus IAP 23% (SAP), 26% (DAP) and 22% (MAP). Correlation of MAP was best and PE lowest before induction of anesthesia for NIBP versus IAP ( r = 0.72; PE 24%) and after intraoperative fluid bolus administration for Nexfin® versus IAP ( r = 0.88; PE: 17.2%). Concordance of MAP trending was 90% (SAP 85%, DAP 89%) for NIBP and 91% (SAP 90%, DAP 86%) for Nexfin®. MAP trending was best during intraoperative ATP positioning for NIBP (97%) and at induction of anesthesia for Nexfin® (97%). Conclusion As compared with IAP, interchangeability of absolute pressure values could neither be shown for NIBP nor Nexfin®, however, NIBP showed poorer overall correlation and precision. Overall trending ability was generally high with Nexfin® surpassing NIBP. Nexfin® may likely render individualized decision-making in the management of different hemodynamic stresses during laparoscopic bariatric surgery, particularly where NIBP cannot be reliably established. Trial registration The non-interventional, observational study was registered retrospectively at ( NCT03184285 ) on June 12, 2017.

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

„Enhanced recovery after surgery“ (ERAS) ist ein multidisziplinäres Behandlungsmodell mit dem Ziel, einen komplikationsärmeren Krankheitsverlauf durch den Erhalt bzw. die frühzeitige Wiederherstellung der patientenspezifischen Homöostase zu gewährleisten. Aus Sicht der Anästhesie ergeben sich in allen 3 Bereichen der perioperativen Phase wesentliche Aspekte, die es umzusetzen gilt, um im Sinne eines vollständigen Behandlungskonzeptes einen optimalen Effekt für den Patienten zu erlangen. Perioperativ gibt es ein Bündel an anästhesiologischen Maßnahmen, die das ERAS-Konzept zu dem machen, was es heute ist. An dieser Stelle soll insbesondere auf die präoperative Vorbereitung und Optimierung der Patienten sowie auf das intra- und postoperative Flüssigkeitsmanagement eingegangen werden. Es wurde eine selektive Literaturrecherche in den Datenbanken Medline und The Cochrane Library durchgeführt, und nationale und internationale Leitlinien wurden berücksichtigt. Aus anästhesiologischer Sicht ergeben sich in allen 3 Säulen der perioperativen Phase relevante Aspekte, deren Einhaltung das Outcome der Patienten verbessern wird: präoperativ eine umfassende Risikoevaluierung sowie der Verzicht auf sedierende Medikamente; intraoperativ die individualisierte Flüssigkeitstherapie im Sinne einer zielorientierten Optimierung; postoperativ die frühe enterale Flüssigkeits- und Nahrungsaufnahme und der Verzicht auf intravenöse Flüssigkeitsgaben, wenn vertretbar. ERAS-Konzepte in den klinischen Alltag zu implementieren und mit einem hohen Maß an Protokolltreue auf die Patienten zu übertragen stellt eine große interdisziplinäre Herausforderung dar, die dringend weiter verfolgt werden muss.

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids ( P < 0.05) and less epinephrine administration ( P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

Background: Treating patients with acute surgical bleeding is common for anaesthesiologists and surgeons. A visual estimation of blood loss is often used in this setting, although studies prove its inaccuracy. Objectives: Which parameters and techniques do anaesthesiologists use to quantify blood loss? Methods: We conducted an online questionnaire survey. The questionnaire was sent to 8 anaesthesiology departments. It comprised 8 questions referring to current blood loss quantification. Results: Data of 215 participants were analysed. The majority (65%) of participants rated visual estimation to be suitable for blood loss quantification. Alternative techniques are unknown in many cases. Conclusion: Visual estimation is a common method applied to determine blood loss. Further investigations evaluating the impact of novel systems on haemotherapy are needed.

Elderly patients aged ≥65 years represent a growing population in the perioperative field, particularly orthopedic and vascular surgery. The higher degree of age‐related or comorbid‐dependent vascular alterations renders these patients at risk for hemodynamic complications and likely denote a possible limitation for modern, non‐invasive arterial pressure monitoring devices. The aim was to compare vascular unloading technique‐derived to invasive measurements of systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) in elderly perioperative patients.

Background In morbidly obese patients undergoing laparoscopic bariatric surgery, the combination of obesity-related comorbidities, pneumoperitoneum and extreme posture changes constitutes a high risk of perioperative hemodynamic complications. Thus, an advanced hemodynamic monitoring including continuous cardiac index (CI) assessment is desirable. While invasive catheterization may bear technical difficulties, transesophageal echocardiography is contraindicated due to the surgical procedure. Evidence on the clinical reliability of alternative semi- or non-invasive cardiac monitoring devices is limited. The aim was to compare the non-invasive vascular unloading to a semi-invasive pulse contour analysis reference technique for continuous CI measurements in bariatric surgical patients. Methods This prospective observational study included adult patients scheduled for elective, laparoscopic bariatric surgery after obtained institutional ethics approval and written informed consent. CI measurements were performed using the vascular unloading technique (Nexfin®) and semi-invasive reference method (FloTrac™). At 10 defined measurement time points, the influence of clinically indicated body posture changes, passive leg raising, fluid bolus administration and pneumoperitoneum was evaluated pre- and intraoperatively. Correlation, Bland-Altman and concordance analyses were performed. Results Sixty patients (mean BMI 49.2 kg/m 2 ) were enrolled into the study and data from 54 patients could be entered in the final analysis. Baseline CI was 3.2 ± 0.9 and 3.3 ± 0.8 l/min/m 2 , respectively. Pooled absolute CI values showed a positive correlation (r s = 0.76, P < 0.001) and mean bias of of − 0.16 l/min/m 2 (limits of agreement: − 1.48 to 1.15 l/min/m 2 ) between the two methods. Pooled percentage error was 56.51%, missing the criteria of interchangeability (< 30%). Preoperatively, bias ranged from − 0.33 to 0.08 l/min/m 2 with wide limits of agreement. Correlation of CI was best (r s = 0.82, P < 0.001) and percentage error lowest (46.34%) during anesthesia and after fluid bolus administration. Intraoperatively, bias ranged from − 0.34 to − 0.03 l/min/m 2 with wide limits of agreement. CI measurements correlated best during pneumoperitoneum and after fluid bolus administration (r s = 0.77, P < 0.001; percentage error 35.95%). Trending ability for all 10 measurement points showed a concordance rate of 85.12%, not reaching the predefined Critchley criterion (> 92%). Conclusion Non-invasive as compared to semi-invasive CI measurements did not reach criteria of interchangeability for monitoring absolute and trending values of CI in morbidly obese patients undergoing bariatric surgery. Trial registration The study was registered retrospectively on June 12, 2017 with the registration number NCT03184272 .

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations. (C) 2019 Elsevier Ltd. All rights reserved.

Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists' (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients.

Zukünftig wird sich eine zunehmende Zahl älterer Patienten mit signifikanten Begleiterkrankungen auch größeren, chirurgischen Eingriffen unterziehen müssen. Perioperative, kardiale Komplikationen sind für viele unerwünschte Ereignisse und Todesfälle verantwortlich. Während der perioperative Myokardinfarkt (PMI) eine allgemein bekannte Komplikation darstellt, waren weniger ausgeprägte Myokardschäden nach nichtherzchirurgischen Eingriffen („myocardial injury after non-cardiac surgery“, MINS) bis vor Kurzem noch nicht Gegenstand der wissenschaftlichen Diskussion. Zwei große Observationsstudien (VISION 1 und VISION 2) haben jedoch eine signifikant erhöhte Letalität bei Auftreten einer MINS gezeigt, wobei selbst geringfügige Anstiege der Troponin-T-Konzentration mit einem erhöhten Sterblichkeitsrisiko assoziiert waren. Diese Übersicht fasst das derzeitige Wissen bezüglich der Entitäten PMI und MINS zusammen und schlägt diagnostische sowie therapeutische Maßnahmen vor, um Risikopatienten optimal durch die perioperative Phase zu geleiten.

The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery. We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery. A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10− 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10− 5 from the GWAS. We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery. The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.

Objective Therapy of complex aortic root pathologies remains a great surgical challenge. Though different graft materials are available to replace the often-destroyed aortic root, long durability and freedom from reoperation of the latter are still under debate. The aim of our study was to investigate patients' postoperative outcome after implantation of the BioIntegral conduit in complex aortic root pathologies. Methods From February 2014 to May 2017, 33 consecutive patients (69.7% male) with a median age of 73 (57.5; 76.2) years underwent aortic root replacement with the BioIntegral conduit at our institution. Severe aortic valve endocarditis (78.8%) was the predominant indication for surgery. In 28 patients (84.9%), implantation was performed as redo or in 87.8% as urgent and emergent surgery. Primary end-point was the 30-day survival time, evaluated by Cox regression analysis. Secondary midterm outcome and graft-related reoperation were analyzed. Results Median follow-up for all patients was 178 (8; 659) days. Median EuroScore II was 19.9% (13.4; 29.9). Freedom from reoperation was 97%. The overall 30-day mortality rate was 33% mainly caused by multiorgan failure in six (18.2%) patients and cardiac failure in five (15.1%) patients. One further death occurred during follow-up at day 156. None was directly conduit-related. Graft reinfection after the 4th surgery with basal abscess formation occurred in only one patient (3%). Early echocardiographic assessment of the valve revealed good functional results. A higher EuroScore II was significantly associated with a poorer 30-day survival time (hazard ratio, 1.039; 95% confidence interval, 1.015–1.063, p = 0.001). Conclusion Aortic root replacement for complex pathologies is associated with substantial 30-day mortality, but survival of patients after discharge from hospital was stable. Early functional status of the BioIntegral valve was good. Though freedom from re-operation was low, long-term outcome and long-term functional status have to be further evaluated.

Right ventricular heart failure is a frequent and serious but often undetected and complex clinical challenge on the intensive care unit. The commonest causes include acute decompensation of pulmonary hypertension, pulmonary embolism, sepsis, acute respiratory distress, and cardiothoracic surgery. The gold standard of bedside diagnosis is a combination of clinical symptoms, biochemical markers (NT-proBNP) and echocardiography. For the purposes of hemodynamic monitoring and treatment management, the indication to place a pulmonary artery catheter should be made generously. The major components of management include treating the underlying disease and triggering factors, reducing pulmonary vascular resistance, increasing contractility, volume optimization, and maintenance of adequate perfusion. Mechanical circulatory support should be considered before irreversible end-organ failure develops.