Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3–4) and distinguished early (first two postoperative hours) and delayed PONV (2–24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7–18.3 and 29.9–24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1–4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects.Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.

Abstract Objective To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. Design Blinded randomised controlled study. Setting Five tertiary care hospitals in Germany. Participants 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. Intervention The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. Main outcome measures The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). Results Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen’s d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. Conclusions Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. Trial registration German Clinical Trial Register DRKS00013800.

Background With a clinical pharmacists' participation in an intensive care unit (ICU) previous international studies have shown a reduction of medication errors, drug costs and improvements of clinical outcomes. Still there is a lack of qualitative data on clinical pharmacists' impact on prescribing error rates in the ICU. Therefore, a new approach was developed relating prescribing errors to the number of monitored medications including physicians' approval on all prescribing errors. Objective This study investigates the influence of clinical pharmacists' medication review on the prescribing error rate in an ICU. Setting A controlled interventional study was conducted in a surgical ICU with one control phase (P0) and two intervention phases (P1 and P2). Method The investigation aimed to determine if the medication review by clinical pharmacists results in a significant reduction of prescribing errors related to a control period. In contrast to previous studies, prescribing errors detected by the clinical pharmacists, were only taken into account, if consent with the physicians was achieved. Secondary outcomes were the reduction of potentially severe prescribing errors, the number of days without systemic anti-infective therapy and the ICU length of stay. Throughout P0 the data was collected retrospectively without any intervention. During the intervention periods P1 and P2, two clinical pharmacists screened the medical records for prescribing errors and discussed them with the senior physician in charge. During P2 one clinical pharmacist attended ward rounds additionally. Main Outcome Measure The main outcome measure of this study was the number of prescribing errors detected related to the number of monitored medications. Results The incidence of prescribing errors was significantly reduced from 1660 in P0 to 622 in P1 respectively 401 in P2 (P0 vs. P1/P2 respectively; both p < 0.001; Fisher's Exact Test) in total, respective 14.12% in P0 vs. 5.13% in P1 and 3.25% in P2 related to the monitored medications (P0:11755; P1:12134; P2:12329). Conclusion Clinical pharmacists' interventions led to a significant reduction of prescribing errors in the ICU, contributing to a safer medication process. We strongly recommend a broad implementation of clinical pharmacists in ICUs.

Zusammenfassung Mit dem Zytokimfilter (Cytosorb®) können Zytokine im Serum reduziert werden. Da Zytokine in die vasodilatatorische Hypotension bei Sepsis involviert sind, könnte ihre Reduktion zu einer Verbesserung der Überlebenschancen von Patienten mit Sepsis beitragen. Trotz einer CE-Zulassung des Verfahrens fehlen bislang Beweise für die klinische Wirksamkeit der Zytokinelimination bei Patienten mit Sepsis. Andere Verfahren, die Zytokine direkt oder indirekt reduzieren, konnten die Mortalität der Sepsis nicht reduzieren. Darüber hinaus besteht die Möglichkeit, dass die unspezifische Adsorption nicht nur proinflammatorische sondern auch antiinflammatorische Zytokine vermindert. Der klinische Effekt könnte durch den Einfluss auf die Interaktion zwischen pro- und antiinflammatorischen Wirkungen bestimmt werden. Vor diesem Hintergrund ist der Nutzen der Zytokinelimination durch Adsorption nicht ohne klinische Daten zu bewerten. Der Einsatz des Verfahrens als Heilversuch beim lebensbedrohlichen septischen Schock sollte nicht ohne kritische Diskussion über den Rahmen, in dem diese Neulandmethode eingesetzt werden kann, erfolgen.

Hemofiltration with Cytosorb can reduce cytokines in sepsis. Since cytokines are involved in the development of vasodilatatory shock in sepsis, their reduction might improve the chance of survival in this condition. In spite of the CE-approval of Cytosorb clinical efficacy has not been proved so far. Other techniques reducing cytokines by direct or indirect manners failed to prove an influence on sepsis mortality. Moreover, the nonspecific elimination of pro- and anti-inflammatory cytokines may result in different clinical effects. Benefits and risks of nonspecific cytokine elimination may be determined by the interaction of pro- and anti-inflammatory cytokines. Therefore, the usefulness of cytokine elimination using Cytosorb cannot be estimated without clinical data. The application of cytosorb in life threatening septic shock should be accompanied by a critical discussion of the limits of these curing trials.

Durch die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) wurde der Auftrag erteilt, die seit 2008 bestehende S2-Leitlinie „Lagerungstherapie zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“ zu revidieren. Aufgrund zunehmender klinischer und wissenschaftlicher Relevanz wurde die Leitlinie um den Themenkomplex „Frühmobilisation“ erweitert. Damit bezieht sie sich auf folgende thematische Schwerpunkte: Einsatz von Lagerungstherapie und Frühmobilisation zur Prophylaxe pulmonaler Funktionsstörungen, Einsatz von Lagerungstherapie und Frühmobilisation zur Therapie pulmonaler Funktionsstörungen, unerwünschte Wirkungen und Komplikationen von Lagerungstherapie und Frühmobilisation sowie praktische Aspekte beim Einsatz von Lagerungstherapie und Frühmobilisation. Diese Leitlinie ist das Ergebnis einer systematischen Literaturrecherche sowie der anschließenden kritischen Evidenzbewertung mit wissenschaftlichen Methoden. Das methodische Vorgehen des Leitlinienentwicklungsprozesses entspricht den Anforderungen an die evidenzbasierte Medizin, wie sie von der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften als Standard definiert wurden. Bezüglich der Lagerungstherapie wurden neu publizierte Arbeiten ab 2005 untersucht; der neu aufgenommene Aspekt der Frühmobilisation umfasst die gesamte bisher publizierte Literatur bis einschließlich 06/2014. Der vorliegende Beitrag gibt die Kurzversion der Leitlinie wieder.

In recent years the development of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has increasingly been perceived as a separate disease entity. About possible trigger mechanisms of SSC-CIP has been speculated, systematic investigations on this issue are still lacking. The purpose of this study was to evaluate the prevalence and influence of promoting factors.

Background: Euthanasia and physician assisted suicide (PAS) are highly debated upon particularly in the light of medical advancement and an aging society. Little is known about the professionals' willingness to perform these practices particularly among those engaged in the field of palliative care and pain management. Thus a study was performed among those professionals.Methods: An anonymous questionnaire was handed out to all participants of a palliative care congress and a pain symposium in 2013. The questionnaire consisted of 8 questions regarding end of life decisions. Proposed patient vignettes were used. Results: A total of 470 eligible questionnaires were returned, 198 by physicians, 272 by nurses. The response rate was 64 %. The majority of professionals were reluctant to perform euthanasia or PAS: 5.3 % of the respondents would be willing to perform euthanasia on a patient with a terminal illness if asked to do so. The reluctance grew in case of a patient with a non-terminal illness. The respondents were more willing to perform PAS than euthanasia. Nurses were more reluctant to take action as opposed to the physicians. The majority of the respondents would attempt to treat the patient's symptoms first before considering life-ending measures. As regards any decision making process the majority would consult with a colleague.Conclusions: This is the first German study to ask about the willingness of professionals to take action as regards euthanasia and PAS without biased phrasing. As opposed to the general acceptance that is respectively high, the actual willingness to perform life-ending measures is low. The German debate on physician assisted suicide and its possible legalization should also incorporate clarifications regarding the responsibility who should eventually perform these acts.

The current debate about end-of-life decisions in Germany focuses on physician-assisted suicide (PAS). However, there is only limited information available on physicians' attitudes towards euthanasia or PAS, and no data on nurses' attitudes.The aim is to explore attitudes of physicians and nurses with a special interest in palliative care and pain medicine using a case-related questionnaire.An anonymous questionnaire, consisting of eight questions, was distributed to all participants of a palliative care congress and a pain symposium. The questions focused on two scenarios: (1) a patient with an incurable fatal illness, (2) a patient with an incurable but nonfatal illness. The question was: Should euthanasia or physician-assisted suicide (PAS) be allowed. In addition, the participants were asked what they wanted for themselves if they were the patient concerned.A total of 317 questionnaires were analyzed; the return rate was 70 %. The general support for euthanasia and PAS was high: 40.5 % supported euthanasia in case of a fatal illness ("definitelyaEuro broken vertical bar aEuroe, "probably should be allowed"), 53.5 % supported PAS. The support decreased in case of a nonfatal illness; however, it increased when the participants were asked about their attitudes if they were the patient concerned. Nurses were more open towards euthanasia and PAS. In physicians the rejection of PAS was directly related to a higher level of qualification in the field of palliative care.The fact that nurses had a more positive attitude towards euthanasia and PAS and that all respondents accepted life-ending acts for themselves more than for their patients hints to still existing severe deficits in Germany.

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Die Diskussion über die sog. Sterbehilfe konzentriert sich zunehmend auf den ärztlich assistierten Suizid (ÄAS), insbesondere angesichts der aktuellen politischen Diskussion. Es gibt jedoch nur wenige aktuelle deutsche Untersuchungen zur Einstellung von Ärzten dazu und keine zu der Einstellung von Pflegekräften.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.Abstract available from the publisher.

Purpose The objective of our trial was to obtain more comprehensive data on the risks and benefits of kinetic therapy in intensive care patients with intracerebral pathology. Methods Standardized data of prone positioning in our NeuroIntensive Care Unit were collected from 2007 onward. A post hoc analysis of all available data was undertaken, with special consideration given to values of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and oxygenation in correlation to prone (PP), or supine positioning (SP) of patients. Cases were considered eligible if kinetic therapy and ICP were documented. Prone positioning was performed in a 135° position for 8 h per treatment unit. Results A total of 115 patients treated with prone positioning from 2007 to 2013 were identified in our medical records. Of these, 29 patients received ICP monitoring. Overall, 119 treatment units of prone positioning with a mean duration of 2.5 days per patient were performed. The mean baseline ICP in SP was 9.5 ± 5.9 mmHg and was increased significantly during PP ( p < 0.0001). There was no significant difference between CPP in SP (82 ± 14.5 mmHg) compared to PP ( p > 0.05). ICP values >20 mmHg occurred more often during PP than SP ( p < 0.0001) and were associated with significantly more episodes of decreased CPP <70 mmHg ( p < 0.0022). The mean paO 2 /FiO 2 ratio (P/F ratio) was increased significantly in prone positioning of patients ( p < 0.0001). Conclusions The analyzed data allow a more precise understanding of changes in ICP and oxygenation during prone positioning in patients with acute brain injury and almost normal baseline ICP. Our study shows a moderate, yet significant elevation of ICP during prone positioning. However, the achieved increase of oxygenation by far exceeded the changes in ICP. It is evident that continuous monitoring of cerebral pressure is required in this patient group.

This study reports on German physicians' views on legalization of euthanasia and physician-assisted suicide, comparing this with a similar survey of UK doctors. A questionnaire was handed out to attendants of a palliative care and a pain symposium. Complete answers were obtained from 137 physicians. Similar to the UK study, about 30% of the physicians surveyed support euthanasia in case of terminal illness and more support physician-assisted suicide. In contrast, in both countries, a great majority of physicians oppose medical involvement in hastening death in non-terminal illnesses. The public and parliamentary discussion should face this opposition to assisted suicide by pain and palliative specialists.

InterpretationBrauchen wir eine Erweiterung des "Versorgungsmodells Akutschmerztherapie"? Wird das Problem chronischer Schmerzen in der perioperativen Phase schmerztherapeutisch vernachlässigt?Glaubt man den Autoren der im vorliegenden Heft von DerAnaesthesist publizierten Arbeit "Vor-

INTRODUCTION:We report the results of an observational study of pain intensity before and after implementation of an algorithm for postoperative pain management. The algorithm included multiple factors for treatment.METHODS:Data of 130 consecutive patients with defined surgical procedures were extracted from charts before and after implementation of the algorithm. Our patients documented pain intensity at rest and on movement on a numerival rating scale (NRS) from 0 (= no pain) to 10 (=  worst pain). A successful pain management was definded as maximum pain intensity at rest ≤ 3 and on movement ≤ 5 on the NRS. For statistical analysis we used the Wilcoxon and the chi squared test.RESULTS:The frequency of a successful pain management increased from 49 % (individual pain management) to 85 % (algorithm) at rest 8 (p < 0.001), on movement the rates were 42 % and 86 %, respectively (p < 0.001). In the total group, we found a reduction of maximum pain intensity at rest (mean ± sd) from 4.05  ±  2.54 to 2.18 ± 1.82 (p < 0.001) and with movement from 6.04 ± 2.51 to 3.5 ± 2.08 (p < 0.001).CONCLUSION:Implementing an algorithm for postoperative pain management resulted in a clinically relevant reduction of postoperative pain. Our findings reflect the result of a complex change in pain management, and therefore cannot be attributed to any single factors involved.

The interpretation of opioid studies in patients with chronic pain due to osteoarthritis is limited by a high dropout rate. Therefore, the implication of dropouts on the recommendation of opioids in chronic osteoarthritis pain was analyzed.