Die transfusionsassoziierte akute Lungeninsuffizienz (TRALI) hat sich nach Einführung der Bezeichnung „TRALI“ durch Popovsky et al. vor annähernd 3 Jahrzehnten zur häufigsten Ursache der transfusionsbedingten Morbidität und Mortalität entwickelt. Vor Implementierung von Maßnahmen zur Risikominimierung, wie der Spenderselektion, war die TRALI überwiegend für transfusionsassoziierte Todesfälle verantwortlich. Plasmareiche Präparate, wie gefrorenes Frischplasma und Thrombozytenkonzentrate, sind als führende Auslöser beschrieben worden. Definitionsgemäß bedeutet die TRALI eine Verschlechterung der Lungenfunktion mit Hypoxämie und Entwicklung von radiologisch gesicherten, nichtkardiogenen, bilateralen Lungeninfiltraten innerhalb von 6 h nach stattgefundener Transfusion. Die Diagnose ist schwierig, und differenzialdiagnostisch müssen Herzinsuffizienz und andere transfusionsbedingte Lungenschäden, wie z. B. „transfusion-associated circulatory overload“ (TACO), unterschieden werden. Eine kausale Therapie ist bisher nicht möglich, daher beschränken sich therapeutische Maßnahmen auf Sauerstoffinsufflation und ggf. mechanische Ventilation. Über die genaue Pathogenese herrscht bisher noch Uneinigkeit. Die in der Literatur favorisierte Hypothese geht von einem „Two-event“-Modell aus, bei der als „first event“ die Sensibilisierung von neutrophilen Granulozyten durch bestimmte Umstände, wie Sepsis oder Trauma, stattfindet. Im Rahmen des „second event“ kommt es durch transfundierte Antikörper (immunogene TRALI) und biologisch aktive Mediatoren (nichtimmunogene TRALI) zur Aktivierung der sensibilisierten neutrophilen Granulozyten mit anschließender Freisetzung von u. a. Proteasen sowie Radikalen, gefolgt von der Entwicklung einer kapillären Leckage und eines Lungenödems. Bis zur Einführung der Spenderselektion, bei der weibliche Spender mit zurückliegenden Schwangerschaften und mit Antikörpern gegen das humane Neutrophilenantigen (HNA) und/oder das humane Leukozytenantigen (HLA) ausgeschlossen werden, schien der Second event durch Transfusion antileukozytärer Antikörper dieser Spendergruppe v. a. immunogener Art zu sein. So konnte die 2009 in Deutschland eingeführte Spenderselektion das Auftreten von tödlichen TRALI-Fällen in den nachfolgenden Jahren vollständig verhindern.

Bei der peripartalen Kardiomyopathie (ppKMP) handelt es sich um eine seltene Art der Herzinsuffizienz, die bei schwangeren Frauen im letzten Monat der Schwangerschaft oder in den ersten 5 postpartalen Monaten auftritt. Abhängig von der geografischen Lage wird eine Inzidenz der ppKMP von 1:300 bis hin zu 1:15.000 in der Literatur angegeben. Es existiert eine Reihe von gesicherten Risikofaktoren (z. B. Multiparität oder Alter der Schwangeren > 30 Jahre). Symptomatisch gesehen entspricht die ppKMP einer idiopathischen Kardiomyopathie. Die Diagnose wird in erster Linie mithilfe der Echokardiographie gestellt, die eine deutliche Reduktion der systolischen linksventrikulären Funktion zeigt. Therapeutisch wird wie bei idiopathischen Kardiomyopathien vorgegangen; in diesem Zusammenhang ist unbedingt auf den Umstand der Schwangerschaft mit den dadurch vorhandenen Kontraindikationen für Therapeutika zu achten. Die Prognose ist von der Erholung der Herzinsuffizienz innerhalb der ersten 6 Monate postpartum abhängig. Die Letalität des Krankheitsbilds ist hoch und wird in der Literatur mit bis zu 28 % angegeben. Aufgrund ihrer Komplexität ist die ppKMP eine interdisziplinäre Herausforderung. Peripartal ist ein enges Zusammenspiel der Disziplinen der Kardiologie, der Herzchirurgie, der Neonatologie, der Geburtshilfe und der Anästhesiologie unabdingbar. Anästhesiologisch stehen der meist fortgeschrittene instabile hämodynamische Zustand der Mutter sowie die Planung und Durchführung des perioperativen Managements im Vordergrund. In der hier ebenfalls vorgestellten Kasuistik wird über eine hochschwangere Patientin mit den Zeichen einer akuten schweren Herzinsuffizienz und der Verdachtsdiagnose einer ppKMP berichtet. Bei der notfallmäßig eingelieferten Patientin erfolgte die Entbindung des Kindes in Periduralanästhesie unter Herz-Lungen-Maschinen-Bereitschaft.

We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery -laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment.

Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.

Transfusion-related acute lung injury (TRALI) developed into the leading cause of transfusion-related morbidity and mortality after the first description by Popovsky et al. approximately three decades ago. It was the most frequent reason for transfusion-related fatalities worldwide before implementation of risk minimization strategies by donor selection. Plasma-rich blood products, such as fresh frozen plasma and apheresis platelets seem to be the leading triggers of TRALI. Hypoxemia and development of pulmonary edema within 6 h of transfusion are the diagnostic criteria for TRALI. The differentiation between cardiac failure and other transfusion-related lung injuries, such astransfusion-associated circulatory overload ( TACO) is difficult and causal treatment is not available. Therapy is based on supportive measures, such as oxygen insufflationor mechanical ventilation. The exactly pathogenesis is still unknown but the most propagated hypothesis is the two-event-model. Neutrophils are primed by the underlying condition, e.g. sepsis or trauma during the first event and these primed neutrophils are activated by transfused leukoagglutinating antibodies (immunogen) or bioreactive mediators (non-immunogen) during the second-event. Transfusion of leukoagglutinating antibodies from female donors with one or more previous pregnancies is the most frequent reason. No more TRALI fatalities were reported after implementation of the donor selection in Germany in 2009.

Die Ursachen eines Lungenödems können unterschiedlichster Genese sein. Im dargestellten Fall kam es bei einer 39-jährigen Patientin zu einer hypertensiv bedingten kardialen Dekompensation mit konsekutivem Lungenödem aufgrund eines bis dahin nicht diagnostizierten Conn-Syndroms.

We report the case of a 46-year-old man who was found in a ditch, alcohol intoxicated, hypothermic and somnolent. The ambient temperature was around 0 degrees C. During the rescue operation the cardiac rhythm degenerated into ventricular fibrillation. Cardiopulmonary resuscitation (CPR) was started and the patient transported to a nearby hospital and later on to the closest university medical center. The patient was transferred to the operating theatre 190 min after the beginning of CPR for rewarming on extracorporeal circulation. The core temperature at that time was 24.7 degrees C. At 30.3 degrees C an attempt at defibrillation resulted in a stable sinus rhythm and the patient was referred to the intensive care unit with mild hypothermia. The patient demonstrated a complete neurological recovery after extubation on day 3.

The aim of this study was to enumerate and identify bifidobacteria from occlusal carious lesions in permanent and deciduous teeth. Samples of infected dentine were obtained from 24 active occlusal lesions in deciduous teeth and from 15 occlusal lesions in permanent teeth. Plaque samples from sound occlusal surfaces of 12 caries-free adults and 12 children were also obtained. The bifidobacterial strains were isolated in mupirocin-containing selective media, Gram-stained and subcultured for identification. Total bacterial counts were determined using fastidious anaerobic agar, and isolates were identified using genus-specific PCR primers and were confirmed by 16S rRNA sequencing. Bifidobacteria were isolated from 13 of the 15 occlusal lesions in the adults and formed 5.09 ± 2.11% of the total cultivable flora. In the children, bifidobacteria were isolated from 16 of the 24 occlusal lesions and formed 7.4 ± 2.6% of the total flora. No bifidobacteria were isolated from the occlusal surfaces of caries-free adults or children. A total of 424 bifidobacteria were identified and these were Bifidobacteriumdentium, Parascardovia denticolens, Scardoviainopicata, Bifidobacterium longum,Scardovia genomosp. C1 and Bifidobacterium breve. B. dentium was present in 14 out of the 16 bifidobacteria-positive samples from the lesions on the deciduous teeth and in 7 out of the 13 positive lesions in adults (p = 0.04). The present data suggest that bifidobacteria may play a role in the progression of occlusal caries lesions in both children and adults.

Wir berichten über einen 46-jährigen Patienten, der bei einer Außentemperatur um 0°C alkoholisiert, somnolent und hypotherm in einem Graben aufgefunden wurde. Während der Rettung entwickelte er Kammerflimmern und wurde unter Reanimation in das nächste Kreiskrankenhaus sowie im weiteren Verlauf in das nächstgelegene Universitätsklinikum transportiert;190 min nach Beginn der Reanimationsmaßnahmen erfolgte bei einer Körperkerntemperatur von 24,7°C der Anschluss an die Herz-Lungen-Maschine. Bei 30,3°C konnte der Patient erfolgreich defibrilliert werden und wurde in milder Hypothermie, die für 12 h beibehalten wurde, auf die Intensivstation verlegt. Der Patient konnte am dritten Tag ohne neurologisches Defizit extubiert werden.

A male patient developed neurological deficits after an uneventful spinal anesthesia. After 2 months without any improvement an epidural hematoma was presumed. Magnet resonance imaging detected inflammatory tissue and destruction at lumbar levels L2/3. The inflammatory tissue had to be removed via laminectomy. Histology of the excised tissue revealed a plasma cell myeloma that was not diagnosed prior to spinal anesthesia 2 months previously.

Ein 78-jähriger männlicher Patient wurde somnolent von einer Notarztwagenbesatzung mit der Verdachtsdiagnose eines apoplektischen Insultes in unsere Notaufnahme gebracht. Unter anästhesiologischer Überwachung wurde eine kraniale Computertomographie durchgeführt, die ergebnislos blieb. Der Patient wurde auf die neurochirurgische Intensivstation gebracht, auf der er vollständig entkleidet wurde. Durch Socke und Unterhose verdeckt, wurden 5 durchsichtige und unbeschriftete Pflaster entdeckt. Unter der Verdachtsdiagnose einer Intoxikation durch ein transdermales Opioid wurde neben der Entfernung der Pflaster eine 3-tägige Therapie mit Naloxon eingeleitet. Der Patient erwachte sofort und konnte über die Verordnung und das Aufkleben der Schmerzpflaster am Vortag berichten. Der Zwischenfall blieb für den Patienten folgenlos.

A rare though extremely harmful complication in neuraxial anaesthesia is an epidural hematoma which can be associated with deleterious consequences for the patient, e. g. persistent paraplegia. The risk of epidural haematomas after neuraxial blockade is dependent on abnormal anatomy of the spine, difficult and multiple punctures and coagulation disorders. Especially when patients undergo therapy with anticoagulants like low molecular heparin or platelet inhibitors (tyclopidine) or a combination of them, the indication for neuraxial blockade must strictly outweigh risk of spinal bleeding. In this context, the precautions and contraindications are the same for spinal puncture and catheter insertion as for catheter removal. We describe the case of a patient who underwent emergency coronary angioplasty in combination with coronary stent implantation due to acute postoperative myocardial infarction following knee replacement in continuous epidural anaesthesia. Under the symptoms of a beginning local infection at the puncture site the epidural catheter had to be removed in spite of ongoing antithrombotic therapy. A possible management of such cases is discussed with regard to risk minimization.

A rare though extremely harmful complication in neuraxial anaesthesia is an epidural hematoma which can be associated with deleterious consequences for the patient, e.g. persistent paraplegia. The risk of epidural haernatomas after neuraxial blockade is dependent on abnormal anatomy of the spine, difficult and multiple punctures and coagulation disorders. Especially when patients undergo therapy with anticoagulants like low molecular heparin or platelet inhibitors (tyclopidine) or a combination of them, the indication for neuraxial blockade must strictly outweigh risk of spinal bleeding. In this context, the precautions and contrainclications are the same for spinal puncture and catheter insertion as for catheter removal. We describe the case of a patient who underwent emergency coronary angioplasty in combination with coronary stent implantation due to acute postoperative myocardial infarction following knee replacement in continuous epidural anaesthesia. Under the symptoms of a beginning local infection at the puncture site the epidural catheter had to be removed in spite of ongoing antithrombotic therapy. A possible management of such cases is discussed with regard to risk minimization.

Background: Major spinal surgery is associated with high postoperative pain scores and opioid requirement. The aim of the current prospective, randomized, placebo-controlled, double-blind study was to assess the reduction of opioid requirement and pain scores using an intraoperatively placed epidural catheter with infusion of 0.1% ropivacaine during the postoperative period.Methods: Thirty patients undergoing major lumbar spinal surgery from a dorsal approach were included in this study. Before wound closure, the orthopedic surgeon inserted an epidural catheter. Postoperatively, patients were randomly assigned to receive an infusion of 12 ml/h ropivacaine, 0.1% (group R), or 12 ml/h saline (group N) after an initial bolus of 10 ml of the respective study solution. Additional pain relief was provided using an intravenous patient-controlled analgesia pump with the opioid piritramide. Patients were assessed with respect to pain scores (visual analog scale of 0-100), cumulative opioid requirement, side effects, and satisfaction with pain management.Results: Demographic data, duration of surgery, and type of surgery were comparable between groups. Pain scores were assessed as follows (group R vs. group N: 6 h: 24 +/- 20 vs. 51 +/- 20, P = 0.002; 24 h: 33 +/- 19 vs. 53 +/- 27, P = 0.04; 48 h: 21 +/- 17 vs. 40 +/- 26, P = 0.04; 72 h: 14 +/- 13 vs. 38 +/- 25, P = 0.02). The cumulative piritramide requirement after 72 h was 97 +/- 23 mg; in group R and 157 72 mg in group N (P = 0.03). The incidence of side effects was comparable between groups, and patient satisfaction was always higher in group R (P < 0.05).Conclusion: Continuous epidural infusion of 0.1% ropivacaine results in lower pain scores and opioid consumption and higher patient satisfaction when compared with placebo. Application of ropivacaine using an epidural catheter seems to be a highly effective treatment for postoperative pain after major lumbar spinal surgery.