Gefäßchirurgische Patienten erfordern eine besondere perioperative Betreuung durch alle beteiligten Fachdisziplinen, weil die Gefäßveränderungen nur selten isoliert auftreten. Patienten mit einer pAVK weisen typische Merkmale und Begleiterkrankungen auf wie Hypercholesterinämie, arterieller Hypertonus, Diabetes mellitus, langjähriger inhalativer Tabakkonsum, männliches Geschlecht und eine positive Familienanamnese. Schlaganfall, Herzinfarkt sowie Durchblutungsstörungen der Beine und der Nieren sind Auswirkungen einer systemischen Gefäßerkrankung und haben damit einen direkten Einfluss auf das perioperative Risiko. Der gefäßchirurgische Patient ist deshalb häufig ein Patient mit erhöhtem Risiko und stellt an die perioperative Versorgung besondere Ansprüche. Der Anästhesist benötigt fundierte pathophysiologische Kenntnisse zu den jeweiligen Begleiterkrankungen, deren spezifischen Risiken und deren möglichen perioperativen Behandlungsoptionen.

BACKGROUNDSupraglottic airway devices (SADs) play an increasing role in airway management in clinical anaesthesia and emergency medicine. Until now, no data exist concerning the extent of oesophageal insufflation when oropharyngeal leak pressures are exceeded.METHODSLaryngeal masks LMA-Supreme™ and LMA-ProSeal™, laryngeal tubes LTS-D and LTS II, Combitube™, and I-Gel were inserted into unfixed human cadavers. The oesophagus was connected to a volumeter, while the trachea was closed surgically to simulate complete airway obstruction. Volumes of oesophageal insufflation resulting from pressure-controlled ventilation at inspiratory pressures of 20, 40, and 60 mbar were measured.RESULTSNo oesophageal insufflation could be detected at a ventilation pressure of 20 mbar in any device. Using inspiratory pressures of 40 and 60 mbar, oesophageal insufflation occurred in all devices, with significantly higher volumes of intraoesophageal air for both laryngeal tubes.CONCLUSIONSThe use of SADs with inspiratory pressures of 20 mbar appears to be safe regarding the risk of intragastric insufflation. Higher inspiratory pressures should be strictly avoided.

Die akute respiratorische Insuffizienz auf dem Boden obstruktiver Ventilationsstörungen ist ein häufig vorkommendes Krankheitsbild im Rettungsdienst. In den meisten Fällen sind dabei der akute Asthmaanfall und die akut exazerbierte chronisch obstruktive Lungenerkrankung (chronic obstructive pulmonary disease − COPD) ursächlich. Eine genaue Differenzierung von Asthma bronchiale und COPD kann präklinisch bei eingeschränkten diagnostischen Möglichkeiten schwierig sein, sodass die Verdachtsdiagnose häufig auf Eigen- oder Fremdanamnese basiert. Es soll insbesondere auf die präklinischen Basismaßnahmen, die pharmakologischen Therapieoptionen und auf die apparativen Verfahren einer Atmungsunterstützung (nicht invasiv vs. invasiv) eingegangen werden.

This study investigated improvements in pre-hospital care for patients with acute exacerbated chronic obstructive pulmonary disease (aeCOPD) achieved by using a standard operating procedure (SOP). An SOP for pre-hospital treatment of patients with aeCOPD was designed based on valid national guidelines. A total of 1000 Emergency Medical Service patient care reports were analysed prospectively: 500 before and 500 after introduction of the SOP. Overall guideline adherence was 34.6% before and 53.8% after introduction of the SOP; this increase was not statistically significant. After SOP introduction, the administration of β2-mimetics by inhalative, intravenous and subcutaneous routes increased significantly. The level of knowledge of the national guidelines was rated at 67% by emergency physicians during self-assessment, but was only 33% when physicians were asked specific questions during interview. Introducing the SOP for patients with aeCOPD did not significantly improve adherence to valid national guidelines, but did help to improve specific elements of therapy.

Das Konzept der Fast-track-Rehabilitation stellt einen multidisziplinären Ansatz dar, um das perioperative Ergebnis zu verbessern. Es wurde bislang in verschiedenen operativen Disziplinen etabliert. Auch im Bereich der Gefäßchirurgie konnten unter Befolgung eines Fast-track-Behandlungspfades gute Erfolge erzielt werden. Die positiven Effekte der Fast-track-Rehabilitation sind jedoch nur durch eine perioperative Kooperation aller beteiligten Professionen zu erzielen. Neben der operativen Fachabteilung hat insbesondere die Anästhesiologie durch ihren direkten Einfluss auf wesentliche Aspekte dieses Konzeptes einen bedeutenden Anteil am klinischen Therapieerfolg. In dieser Arbeit sollen die einzelnen anästhesiologischen Behandlungsansätze bei Anwendung der Fast-track-Rehabilitation im Bereich der Gefäßchirurgie näher betrachtet werden.

The fast-track concept, a multidisciplinary approach to improve perioperative outcomes, has now been established in numerous surgical disciplines. Its application in vascular surgery has also been successfully demonstrated. The positive effects of fast-track rehabilitation can be achieved only by the cooperation of all professionals involved. Besides the surgeon, the anaesthesiologist plays a key role in perioperative management in fast-track programmes through his or her direct influence on substantial aspects of the fast-track concept. In this review, the authors describe therapeutic approaches of the anaesthesiologist using a fast-track concept in vascular surgery.

Fast-track surgery is a therapeutic concept for minimizing perioperative complications by strictly controlling preoperative and postoperative risk factors. This concept was introduced in the 1990s by the Danish surgeon Prof. Kehlet and the aim is to avoid general and specific drawbacks and an optimized rehabilitation. A core part of the fast-track concept is mobilization of the patient beginning on the same day as surgery. Although strongly disputed during the first years after introduction, this method has now become established in general surgery in Germany since 2004. However, there is still a lack of data in the literature on fast-track concepts in vascular surgery.

Die Fast-track-Chirurgie ist ein therapeutisches Konzept, das durch die Anwendung bestimmter Behandlungsmaßnahmen allgemeine Komplikationen nach operativen Eingriffen vermeiden soll. Es wurde Ende der 1990er Jahre von dem dänischen Chirurgen Prof. Kehlet entwickelt und erprobt. Ziel ist die Vermeidung allgemeiner und operationsspezifischer Komplikationen und eine optimierte Rehabilitation. Fester Bestandteil der Fast-track-Rehabilitation ist eine zeitnahe Mobilisation des Patienten noch am Operationstag. Anfangs heftig umstritten, etabliert sich die Methode seit 2004 in Deutschland. In der Gefäßmedizin sind bis dato nur wenige Fast-track-Konzepte aus der Literatur bekannt.

This study investigated the effects of propofol on primary neuronal cultures from rat embryos. Primary cortical neuronal cultures were prepared from Wistar rat embryos (E18). The viability of cells exposed to 0.01, 0.1 or 1 mg/ml propofol for up to 48 h was assessed using a methyltetrazolium assay. In order to evaluate the role of gamma-aminobutyric acid-A (GABA(A)) receptors, cells were also preincubated with the GABA(A)-receptor antagonists, gabazine and picrotoxin. Propofol at a concentration of 1 mg/ml significantly reduced cell viability after 12 h. In contrast, this concentration led to a significant increase in cell viability at 3 and 6 h. The GABA(A)-receptor antagonists did not influence the neurodegenerative effect of propofol but abolished its neuroprotective effect. DNA fragmentation as a marker of apoptosis was elevated after 24 h propofol treatment. These results confirm that high doses of propofol can cause GABA(A) receptor triggered neuroprotection and a subsequent time-dependent, but GABA(A) independent, neurodegeneration in primary cortical neurons.

Paediatric craniofacial surgery (pCFS) regularly requires transfusion of packed red blood cells (pRBC). In this clinical pilot study two different transfusion regimens were prospectively compared concerning pRBC transfusions, postoperative bleeding and other clinical parameters. Thirty infants (aged < 12 months) scheduled for pCFS were assigned to receive fresh frozen plasma (FFP-group, n = 15) or 5% human albumin (HA-group, n = 15) during the entire surgical procedure. Perioperative amounts of pRBC, postoperative bleeding, major complications, duration of stay in the intensive care unit and overall hospital stay were compared. Differences in pRBC transfusions, postoperative bleeding, and duration of intensive care unit stay were not significant and no major complications occurred in either group. A significantly shorter overall hospital stay was observed in favour of the FFP-group. Volume replacement during pCFS can be safely performed with both applied protocols. Our data do not demonstrate a major advantage for FFP use, but further evaluation is necessary.

Background. Supraglottic airway devices are increasingly used in anaesthesia and emergency medicine. This study was designed to investigate the oesophageal seal of the novel supralaryngeal airway device, I-Gel (TM) (I-Gel), in comparison with two of the laryngeal mask airways, Classic (TM) (cLMA) and ProSeal (TM) (pLMA), in a model of elevated oesophageal pressure.Methods. The three supralaryngeal airway devices were inserted into eight unfixed cadaver models with exposed oesophagi that had been connected to a water column producing both a slow and a fast oesophageal pressure increase. The pressure applied until the loss of oesophageal seal during a slow and fast pressure increase was measured.Results. During the slow increase of pressure, the pLMA withstood an oesophageal pressure up to a median of 58 cm H2O, while the cLMA was able to block the oesophagus up to a median of 37 cm H2O, and I-Gel already lost its seal at 13 cm H2O. One minute after maximum pressure had been applied, the pLMA withstood an oesophageal pressure of 59 cm H2O, the cLMA of 46 cm H2O, and I-Gel airway of 21 cm H2O. A fast release of oesophageal fluid was accomplished through the oesophageal lumen of both the pLMA and I-Gel.Conclusions. Both the pLMA and cLMA provided a better seal of the oesophagus than the novel I-Gel airway. The pLMA and I-Gel drain off gastrointestinal fluid fast through the oesophageal lumen. Thus, tracheal aspiration may be prevented with their use. Further study is necessary.

Die kardiopulmonale Reanimation (CPR) bei Kindern ist ein emotionsbehaftetes Ereignis. Laienhelfer ergreifen aus Angst, etwas falsch zu machen, oft nur verzögert oder gar keine lebensrettende Sofortmaßnahmen. Aber auch dem medizinischen Personal fehlt zuweilen die Routine im Umgang mit dem kindlichen Notfallequipment – unkoordiniertes Handeln in der Akutsituation ist die Folge. Dieser Beitrag stellt die Grundlagen der aktuellen ERC-Richtlinien einschließlich Basic und Advanced Life Support dar. Darüber hinaus nennt er Empfehlungen zur Postreanimationstherapie und zur Einbindung der Eltern.

BACKGROUND:Peritoneal carcinomatosis is a stage of gynecological and gastrointestinal malignancies with poor prognosis. Options for enhancing the effect of standard chemotherapy, such as aggressive surgery and intraperitoneal chemotherapy, have limitations. In this phase I/II study, we evaluated regional hyperthermia of the pelvis and abdomen using the annular-phased-array technique as an adjunct to chemotherapy.METHODS:Forty-five patients with peritoneal carcinomatosis (with or without liver metastases) in colorectal cancer (CRC) (n = 16), ovarian cancer (OC) (n = 17), or gastric/pancreatic/biliary cancer (n = 12) underwent standard chemotherapy and regional hyperthermia. Most CRC patients received second-line chemotherapy. All OC patients were platinum resistant. Regional hyperthermia was applied using a SIGMA-60 applicator (OC), a SIGMA-Eye/MR applicator (CRC), or various ring applicators (gastric/pancreatic/biliary cancer).RESULTS:Abdominal regional hyperthermia was well tolerated, with acceptable acute discomfort and no long-term morbidity. The SIGMA-Eye/MR applicator achieved higher systemic temperatures (associated with higher systemic stress) and more effective heating of the upper abdomen; the SIGMA-60 applicator achieved higher temperatures (and power densities) in the pelvis. Three-year overall survival was encouraging for patients with CRC (22%) and OC (29%) but not gastric/pancreatic/biliary cancer. For the SIGMA-60 applicator (patients with OC), higher measured temperatures at the vaginal stump correlated with better outcome. CONCLUSIONS. The SIGMA-60 and SIGMA-Eye/MR applicators are feasible for abdominal heating and have low toxicity. The SIGMA-60 applicator is specifically suitable for malignancies with high pelvic burden; the SIGMA-Eye/MR applicator better heats the upper abdomen, including the liver. Further randomized investigations are warranted.

A case of a premature infant with tracheal atresia together with an exceptional combination of congenital abnormalities that partially corresponds to the TACRD and VACTERL associations is presented. Tracheal atresia was not detectable in the prenatal ultrasound due to lacking of the typical diaphragmatic and pulmonary findings because of the esophago-tracheal fistula, and therefore the resuscitation team was not prepared for this severe airway complication. After prolonged resuscitation efforts were terminated and the newborn expired after birth. Even without typical warning signs physicians have to be aware of tracheal atresia and airway obstruction if VACTERL or TACRD associations are diagnosed.

Recently, it has been demonstrated that exposure of the developing brain to antiepileptic or anaesthetic drugs with GABAA-enhancing and/or NMDA receptor-blocking properties may induce apoptotic neurodegeneration. Propofol and sevoflurane as commonly used drugs in pediatric anaesthesia have been shown to act primarily by GABAA-receptors enhancement. The aim of this study was to assess the neurodegenerative effects of propofol or sevoflurane exposure to newborn rats.

Percutaneous central venous cannulation of small infants is a challenging procedure. The use of ultrasound guidance has been shown to increase the success rate generally in children and to decrease the incidence of associated complications. To demonstrate that this technique is also suitable in very small infants we describe the case of a preterm neonate of 850 g body weight (BW), in which percutaneous central venous cannulation was performed successfully using ultrasound imaging for guidance.

The term 'extreme' whole-body hyperthermia (WBH) describes the procedure of raising a patients' body-core temperature to 41.5-42.0 degrees C for 60 min. WBH represents the only hyperthermia technique that enables systemic heat treatment in patients with disseminated malignancies and is, therefore, usually combined with systemic chemotherapy. Up to now, several WBH-approaches have proved to be safe and associated with acceptable toxicity rates when radiant heat devices are employed. Until the late 1990s, the use of radiant WBH was restricted to a few specialized treatment centres worldwide. During the last 5 years, a larger number of WBH-devices were put into operation particularly in Germany. As a result, a novel generation on phase II trials on chemotherapy and adjunctive WBH in patients with various malignancies has been completed. Based on the promising results observed herein, first multi-centric phase III-trials on chemotherapy +/- WBH have been initiated, with a considerable number of patients treated at German institutions. The authors are members of the 'Interdisciplinary Working Group for Hyperthermia' ('Interdisziplinäre Arbeitsgruppe Hyperthermie'), a sub-group of the German Cancer Society. They formulated these guidelines in order to standardize the WBH treatment procedure and supportive measures, to provide some uniformity in the selection of patients to be treated and to define criteria of a successful WBH-treatment. These recommendations may be helpful to ensure the quality of WBH performed at different institutions.

OBJECTIVES:To optimize volume therapy during induced whole-body hyperthermia (WBH) < or = 42.2 degrees C, pulmonary capillary wedge pressure (PCWP) and intrathoracic blood volume index (ITBVI) were compared as goal parameters. DESIGN:Prospective clinical study. SETTING:ICU at university hospital. PATIENTS:Twenty-three patients with metastatic cancers. INTERVENTIONS:Radiant WBH in combination with induced hyperglycemia, hyperoxemia, and chemotherapy was applied. Volume therapy was directed to the PCWP (group A, 8 to 12 mm Hg [20 treatments]), or to ITBVI (group B, 800 to 1,100 mL/m2 [19 treatments]) following a standardized protocol. Goals other than PCWP and ITBVI were cardiac index of > 3.5 L/min/m2 and mean arterial pressure of > 55 mm Hg. MEASUREMENTS AND RESULTS:In addition to the primary goals PCWP and ITBVI, at defined temperatures, central venous pressure (CVP), extravascular lung water index, the number of infusions, and packed RBCs, as well as serum lactate level, norepinephrine dosage, and levels of liver enzymes, bilirubin, creatinine, and urea were measured. Patients in group A received a significantly greater mean (+/- SD) amount of crystalloids compared to those in group B (6,175 +/- 656 vs 3,947 +/- 375 mL, respectively) and required significantly lower dosages of vasoconstrictors compared with patients in group B. Except for the lower values of CVP in patients in group A during hyperthermia, all of the other hemodynamic and laboratory parameters showed no significant differences between the groups or stayed in a normal range. CONCLUSION:PCWP and ITBVI are useful parameters to assess preload in induced WBH. Differences in crystalloids and vasopressor dosages may suggest an appropriate ITBVI of > 1,100 mL/m2 for patients with good cardiopulmonary health under such extremely hypercirculatory conditions.

This phase I/II study evaluated the feasibility, toxicity and response rates of von Ardenne's systemic cancer multistep therapy (sCMT) when applied as an adjunct to cytostatic therapy in patients with metastatic colorectal cancer. sCMT consists of whole-body hyperthermia (WBH) at 41.8-42.1 degrees C, hyperglycaemia and hyperoxaemia. All patients who entered the trial first received three monthly courses of chemotherapy (folinic acid, 50 mg, days 1-5; 5-fluorouracil, 425 mg/m2, days 1-5; mitomycin 8 mg/m2, day 1), followed by response evaluation according World Health Organization (WHO) criteria. Responders (partial/complete remission) were assigned to three further courses of chemotherapy, whereas non-responders (stable/progressive disease) were allocated to additional sCMT on day 1 of every subsequent chemotherapy course. The WBH procedure was administered under general anaesthesia employing the Iratherm-2000 radiant heat device. Of 28 patients enrolled, 19 received more than three treatment courses. Eight of these 19 patients had responded to chemotherapy (PR) and thus obtained three further courses of chemotherapy alone. In 10 of 19 patients who had not responded (SD, PD), three additional courses of chemotherapy were combined with sCMT (with 25 sCMT applications). One patient who did not respond to initial treatment declined sCMT and was continued with chemotherapy alone. It was found that sCMT was feasible, but associated with a specific spectrum of grade III/IV toxicity (skin 20%, pain 16%, peripheral nerves 8% of treatment courses). The fact that three patients who did not respond to initial chemotherapy achieved a PR after additional sCMT suggests that sCMT may enhance the effect of chemotherapy in patients with colorectal cancer.

Objective : In order to investigate the safety of whole body hyperthermia (WBH) within the context of systemic Cancer Multistep Therapy (sCMT) in patients with disseminated malignancies, cardiopulmonary changes and various organ functions were examined.Methods and procedures : Fifty-seven sCMT treatments were performed in 22 patients. WBH with a plateau phase of 1 h at 41.8degreesC was induced by an IRATHERM 2000 device. Cardiopulmonary parameters were measured at 37, 40, 41.8 and 39 degreesC by use of a pulmonary artery catheter, femoral oxymetry and a radial artery catheter. Organ functions of the liver, kidney, cardiovascular and central nervous system were evaluated before and after treatment.Results : Compared with the initial values, significant alterations were found of most cardiopulmonary parameters in the sense of hypercirculation at 41.8 degreesC. With the exception of extra vascular lung water index, all parameters showed a clear tendency towards the pre-treatment levels at 39 8 In eight out of 57 sCMT treatments, reversible organ dysfunctions were observed. Comparison of radial and femoral arterial blood pressure showed significantly different values at 40 and 41.8 degreesC.Conclusions : WBH induces cardiovascular stress, but by careful selection of patients and appropriate anaesthesiological monitoring it can be performed safely using general anaesthesia. This enables further evaluation of WBH in multimodal treatment concepts.