A. von Goedecke

Oben mit bitte

Vor ca. 0 Jahren war die Angst vor einer Infektion mit dem Aidsvirus bei der Mundzu-Mund-Beatmung in der Bevölkerung besonders groß [7]. Aufgrund dieser ablehnenden öffentlichen Meinung sah sich die Wissenschaft gezwungen, mögliche Alternativen für die Mund-zu-Mund-Beatmung zu finden. Es wurde z. B. spekuliert, ob ggf. auf eine Beatmung bei der kardiopulmonalen Reanimation (CPR) zumindest kurzzeitig verzichtet werden könnte. Als Begründung wurde u. a. der niederländische „CAB-Ansatz“ („circulation“/Herzdruckmassage – “airway“/Atemweg – “breathing“/Beatmung) im Gegensatz zum traditionellen „ABC-Ansatz“ angeführt, der als regionale CPR-Empfehlung seit vielen Jahren in den Niederlanden verwendet wird. Bei näherer Betrachtung ist die CAB-Grundlage ein Abstract aus dem Jahre 983 [0]; der genaue Artikel wurde nie veröffentlicht. In diesem Experiment wurden kardial reanimierten Hunden arterielle Blutgasanalysen abgenommen, die sich tatsächlich erst nach 45-s-Thoraxkompressionen signifikant von den Kontrollmessungen vor dem Versuch unterschieden.

Anästhesie außerhalb des Zentral-OP

The number of diagnostic and surgical procedures being performed outside the core operating area is growing disproportionately. Due to the higher perioperative risk for such patients, anesthesia should only be provided by a very experienced anesthesiologist, even for supposedly small interventions. At these locations, timely and direct access to the anesthesia machine and/or the patient is often limited and if additional personnel or supplies are required, substantial time delays usually occur and should be allowed for. Standard operating procedures that are optimized to local requirements and providing a specially equipped anesthesia trolley for diagnostic and surgical procedures outside of the core operating area, may decrease the likelihood of complications induced by poorly equipped anesthesia workplaces. For electroconvulsive therapy (ECT), the standard drugs are methohexital in combination with short-acting opioids, such as remifentanil and succinylcholine. Significant variations in arterial blood pressure and heart rate are possible. Anesthesia induction in children with a known difficult airway or difficult intravascular access should initially be performed in a location with optimal infrastructure with subsequent transfer to the diagnostic or surgical suite outside the core operating area. Before entering the magnetic resonance imaging (MRI) suite, personal ferromagnetic items (e.g. pens, credit cards, stethoscopes, keys, telephones, USB sticks) should be removed to prevent injury and data loss; a MRI-compatible anesthesia machine and equipment is compulsory. Patients with cardiac pacemakers, cochlea implants, aneurysm or other clips, metallic-based tattoos or make-up are not normally compatible with MRI. General anesthesia should be preferred over conscious sedation for magnetic resonance imaging and ear protection is necessary for anesthetized patients. Gastroscopy in children should be performed under general anesthesia; and when concluding the procedure, air insufflated into the gastrointestinal tract should be suctioned in all patients. For angiography, maximum monitoring needs to be available to provide hemodynamically unstable patients with adequate anesthesia care; comprehensive radiation protection for patients and staff as well as temperature monitoring for prolonged diagnostic procedures is also necessary. Monitoring oxygen saturation and end-tidal carbon dioxide as well as employing visual and audible alarms is an essential requirement even during conscious sedation. In summary, the number of diagnostic and surgical procedures performed outside the core operating area should be reduced to a minimum and, whenever possible, diagnostic or surgical procedures should be performed within the core operating area.ZusammenfassungDie Anzahl der chirurgischen und diagnostischen Interventionen an Arbeitsplätzen außerhalb des Zentral-OP steigt überproportional. Aufgrund des hohen perioperativen Risikos der dort behandelten Patienten sollten Narkosen und Analgosedierungen– auch bei vermeintlich kleinen Eingriffen – nur von sehr erfahrenen Anästhesisten erbracht werden. Der Zugang zum Narkosegerät und/oder zum Patienten ist oft räumlich und zeitlich eingeschränkt; erhebliche Zeitverzögerungen bei Bedarf an zusätzlichem Material und Personal sind einzukalkulieren. Durch das Erstellen hausinterner Checklisten oder durch die Bereitstellung eines Anästhesiewagens speziell für Eingriffe außerhalb des Zentral-OP können Komplikationen durch schlecht ausgerüstete Arbeitsplätze vermieden werden. In der Elektrokrampftherapie (ECT) sind Methohexital ggf. in Kombination mit einem kurz wirksamen Opiat wie Remifentanil und Succinylcholin die Standardmedikamente. Starke Schwankungen von Blutdruck und Herzfrequenz sind möglich. Die Anästhesieeinleitung von Kindern bei bekannt schwierigem Atemweg oder schwierigem Gefäßzugang in einem Bereich mit optimaler Infrastruktur und erst der sekundäre Transport zum Interventionsarbeitsplatz sollten erwogen werden. Vor dem Betreten des Magnetresonanztomographen (MRT) sollten ferromagnetische Gegenstände (Kugelschreiber, Kreditkarten, Stethoskope, Schlüsselbund, Telefone, USB-Sticks) zur Vermeidung von Verletzungen und Datenverlusten abgelegt werden; ein MRT-kompatibles Anästhesiegerät und Monitoringausrüstung sind zwingend erforderlich. Patienten mit Herzschrittmachern, Cochleaimplantaten, Aneurysmaclips, metallhaltigen Tattoos und Make-up etc. sind in der Regel nicht MRT-kompatibel. Im MRT ist eine Allgemeinanästhesie der Analgosedierung vorzuziehen; Gehörschutz ist auch bei anästhesierten Patienten notwendig. Gastroskopie ist bei Kindern bevorzugt in Intubationsnarkose durchzuführen. Wichtig ist das Absaugen der in den Gastrointestinaltrakt eingebrachten Luft am Interventionsende bei allen Patienten. In der Angiographie ist eine Maximalüberwachung erforderlich, um auch hämodynamisch instabile Patienten adäquat zu versorgen. Ebenfalls sind ein umfassender Strahlenschutz für Personal und Patient sowie eine Temperaturüberwachung bei längeren Interventionen erforderlich. Die Anwendung von Pulsoxymetrie, Kapnographie, optischen und akustischen Alarmen ist auch bei Analgosedierungen essenziell. Insgesamt sollte versucht werden, die Anzahl der operativen Eingriffe und Interventionen außerhalb des Zentral-OP auf ein Minimum zu reduzieren und, wann immer möglich, den Eingriff unter optimalen Bedingungen im zentralen OP-Bereich durchzuführen.AbstractThe number of diagnostic and surgical procedures being performed outside the core operating area is growing disproportionately. Due to the higher perioperative risk for such patients, anesthesia should only be provided by a very experienced anesthesiologist, even for supposedly small interventions. At these locations, timely and direct access to the anesthesia machine and/or the patient is often limited and if additional personnel or supplies are required, substantial time delays usually occur and should be allowed for. Standard operating procedures that are optimized to local requirements and providing a specially equipped anesthesia trolley for diagnostic and surgical procedures outside of the core operating area, may decrease the likelihood of complications induced by poorly equipped anesthesia workplaces. For electroconvulsive therapy (ECT), the standard drugs are methohexital in combination with short-acting opioids, such as remifentanil and succinylcholine. Significant variations in arterial blood pressure and heart rate are possible. Anesthesia induction in children with a known difficult airway or difficult intravascular access should initially be performed in a location with optimal infrastructure with subsequent transfer to the diagnostic or surgical suite outside the core operating area. Before entering the magnetic resonance imaging (MRI) suite, personal ferromagnetic items (e.g. pens, credit cards, stethoscopes, keys, telephones, USB sticks) should be removed to prevent injury and data loss; a MRI-compatible anesthesia machine and equipment is compulsory. Patients with cardiac pacemakers, cochlea implants, aneurysm or other clips, metallic-based tattoos or make-up are not normally compatible with MRI. General anesthesia should be preferred over conscious sedation for magnetic resonance imaging and ear protection is necessary for anesthetized patients. Gastroscopy in children should be performed under general anesthesia; and when concluding the procedure, air insufflated into the gastrointestinal tract should be suctioned in all patients. For angiography, maximum monitoring needs to be available to provide hemodynamically unstable patients with adequate anesthesia care; comprehensive radiation protection for patients and staff as well as temperature monitoring for prolonged diagnostic procedures is also necessary. Monitoring oxygen saturation and end-tidal carbon dioxide as well as employing visual and audible alarms is an essential requirement even during conscious sedation. In summary, the number of diagnostic and surgical procedures performed outside the core operating area should be reduced to a minimum and, whenever possible, diagnostic or surgical procedures should be performed within the core operating area.

Analgosedierung mit Remifentanil bei spontan atmenden Patienten für Eingriffe in der interventionellen Radiologie

INTRODUCTION Percutaneous transhepatic biliary drainage (PTBD) and stenting are very painful procedures in interventional radiology and require potent analgesia; employing remifentanil in spontaneously breathing patients may be one possible strategy. PATIENTS AND METHODS The study group was composed of 18 men and 2 women with a mean age of 63+/-10 (mean+/-SD) years. Pain intensity was measured with a VAS score before the procedure, after local anesthesia on the rib cage, after stenting and after the radiology procedure. RESULTS Remifentanil infusion (dosage: 0.12-0.30 microg/kg body weight/min) was infused throughout the entire radiology procedure according to physical status, past medical history, individual pain, and clinical assessment. During insufflation of 10l O(2)/min via a venturi mask, oxygen saturation did not fall below 96% at any time-point during the procedure. In the VAS score, we noted a decrease after starting the remifentanil infusion towards the end of procedure. All patients were able to move into bed without help. Postoperatively, no analgesics and no antiemetics were needed. CONCLUSIONS Employing a remifentanil infusion for brief interventional radiology procedures in palliative treatment of patients resulted in high patient and radiologist comfort.

„Briefing-Check“ Anästhesie@@@Anesthetist’s briefing check: Werkzeug zur Verbesserung der Patientensicherheit im OP@@@Tool to improve patient safety in the operating room

Adverse events are not unusual in a more and more complex anesthesiological environment. The main reasons for this are an increasing workload, economic pressure, growing expectations of patients and deficits in planning and communication. However, these incidents mostly do not refer to medical deficits but to flaws in non-technical skills (team organisation, task orientation, decision making and communication). The introduction of the WHO Safe Surgery Checklist depicted that a structural approach can improve the situation. However, it is still questionable if this measure is strong enough and recent publications revealed initial criticisms. Furthermore, remaining security gaps could be found even though the checklist was implemented in the anesthesiological practice of a big teaching hospital. Therefore, an additional checklist was developed to implement an anesthesia briefing in the daily routine. The main objective was to establish a security check before induction similar to the aeronautical pre-flight check. Additionally, this measure should improve coordination of the anesthesiology team. Working through the checklist, doctors and nurses are guided to focus on conjoint patient care prior to induction of anesthesia. In a web-based survey the general attitude of coworkers towards patient safety, as well as the acceptability of the new briefing check was scrutinised at two times: directly before implementation of the checklist and 1 year after. The results (84 % of medical and 97 % of healthcare staff answered the questionnaires) showed improvements with high relevance to parameters associated with awareness concerning safety issues and team coordination. In conclusion, it appears that patient safety can be significantly improved with little time effort of 3-5 min per patient. A prospective trial will be conducted to confirm the impact of this measure on improvements in patient safety.

Anästhesie außerhalb des Zentral-OP@@@Anesthesia outside the core operating area

The number of diagnostic and surgical procedures being performed outside the core operating area is growing disproportionately. Due to the higher perioperative risk for such patients, anesthesia should only be provided by a very experienced anesthesiologist, even for supposedly small interventions. At these locations, timely and direct access to the anesthesia machine and/or the patient is often limited and if additional personnel or supplies are required, substantial time delays usually occur and should be allowed for. Standard operating procedures that are optimized to local requirements and providing a specially equipped anesthesia trolley for diagnostic and surgical procedures outside of the core operating area, may decrease the likelihood of complications induced by poorly equipped anesthesia workplaces. For electroconvulsive therapy (ECT), the standard drugs are methohexital in combination with short-acting opioids, such as remifentanil and succinylcholine. Significant variations in arterial blood pressure and heart rate are possible. Anesthesia induction in children with a known difficult airway or difficult intravascular access should initially be performed in a location with optimal infrastructure with subsequent transfer to the diagnostic or surgical suite outside the core operating area. Before entering the magnetic resonance imaging (MRI) suite, personal ferromagnetic items (e.g. pens, credit cards, stethoscopes, keys, telephones, USB sticks) should be removed to prevent injury and data loss; a MRI-compatible anesthesia machine and equipment is compulsory. Patients with cardiac pacemakers, cochlea implants, aneurysm or other clips, metallic-based tattoos or make-up are not normally compatible with MRI. General anesthesia should be preferred over conscious sedation for magnetic resonance imaging and ear protection is necessary for anesthetized patients. Gastroscopy in children should be performed under general anesthesia; and when concluding the procedure, air insufflated into the gastrointestinal tract should be suctioned in all patients. For angiography, maximum monitoring needs to be available to provide hemodynamically unstable patients with adequate anesthesia care; comprehensive radiation protection for patients and staff as well as temperature monitoring for prolonged diagnostic procedures is also necessary. Monitoring oxygen saturation and end-tidal carbon dioxide as well as employing visual and audible alarms is an essential requirement even during conscious sedation. In summary, the number of diagnostic and surgical procedures performed outside the core operating area should be reduced to a minimum and, whenever possible, diagnostic or surgical procedures should be performed within the core operating area.ZusammenfassungDie Anzahl der chirurgischen und diagnostischen Interventionen an Arbeitsplätzen außerhalb des Zentral-OP steigt überproportional. Aufgrund des hohen perioperativen Risikos der dort behandelten Patienten sollten Narkosen und Analgosedierungen– auch bei vermeintlich kleinen Eingriffen – nur von sehr erfahrenen Anästhesisten erbracht werden. Der Zugang zum Narkosegerät und/oder zum Patienten ist oft räumlich und zeitlich eingeschränkt; erhebliche Zeitverzögerungen bei Bedarf an zusätzlichem Material und Personal sind einzukalkulieren. Durch das Erstellen hausinterner Checklisten oder durch die Bereitstellung eines Anästhesiewagens speziell für Eingriffe außerhalb des Zentral-OP können Komplikationen durch schlecht ausgerüstete Arbeitsplätze vermieden werden. In der Elektrokrampftherapie (ECT) sind Methohexital ggf. in Kombination mit einem kurz wirksamen Opiat wie Remifentanil und Succinylcholin die Standardmedikamente. Starke Schwankungen von Blutdruck und Herzfrequenz sind möglich. Die Anästhesieeinleitung von Kindern bei bekannt schwierigem Atemweg oder schwierigem Gefäßzugang in einem Bereich mit optimaler Infrastruktur und erst der sekundäre Transport zum Interventionsarbeitsplatz sollten erwogen werden. Vor dem Betreten des Magnetresonanztomographen (MRT) sollten ferromagnetische Gegenstände (Kugelschreiber, Kreditkarten, Stethoskope, Schlüsselbund, Telefone, USB-Sticks) zur Vermeidung von Verletzungen und Datenverlusten abgelegt werden; ein MRT-kompatibles Anästhesiegerät und Monitoringausrüstung sind zwingend erforderlich. Patienten mit Herzschrittmachern, Cochleaimplantaten, Aneurysmaclips, metallhaltigen Tattoos und Make-up etc. sind in der Regel nicht MRT-kompatibel. Im MRT ist eine Allgemeinanästhesie der Analgosedierung vorzuziehen; Gehörschutz ist auch bei anästhesierten Patienten notwendig. Gastroskopie ist bei Kindern bevorzugt in Intubationsnarkose durchzuführen. Wichtig ist das Absaugen der in den Gastrointestinaltrakt eingebrachten Luft am Interventionsende bei allen Patienten. In der Angiographie ist eine Maximalüberwachung erforderlich, um auch hämodynamisch instabile Patienten adäquat zu versorgen. Ebenfalls sind ein umfassender Strahlenschutz für Personal und Patient sowie eine Temperaturüberwachung bei längeren Interventionen erforderlich. Die Anwendung von Pulsoxymetrie, Kapnographie, optischen und akustischen Alarmen ist auch bei Analgosedierungen essenziell. Insgesamt sollte versucht werden, die Anzahl der operativen Eingriffe und Interventionen außerhalb des Zentral-OP auf ein Minimum zu reduzieren und, wann immer möglich, den Eingriff unter optimalen Bedingungen im zentralen OP-Bereich durchzuführen.AbstractThe number of diagnostic and surgical procedures being performed outside the core operating area is growing disproportionately. Due to the higher perioperative risk for such patients, anesthesia should only be provided by a very experienced anesthesiologist, even for supposedly small interventions. At these locations, timely and direct access to the anesthesia machine and/or the patient is often limited and if additional personnel or supplies are required, substantial time delays usually occur and should be allowed for. Standard operating procedures that are optimized to local requirements and providing a specially equipped anesthesia trolley for diagnostic and surgical procedures outside of the core operating area, may decrease the likelihood of complications induced by poorly equipped anesthesia workplaces. For electroconvulsive therapy (ECT), the standard drugs are methohexital in combination with short-acting opioids, such as remifentanil and succinylcholine. Significant variations in arterial blood pressure and heart rate are possible. Anesthesia induction in children with a known difficult airway or difficult intravascular access should initially be performed in a location with optimal infrastructure with subsequent transfer to the diagnostic or surgical suite outside the core operating area. Before entering the magnetic resonance imaging (MRI) suite, personal ferromagnetic items (e.g. pens, credit cards, stethoscopes, keys, telephones, USB sticks) should be removed to prevent injury and data loss; a MRI-compatible anesthesia machine and equipment is compulsory. Patients with cardiac pacemakers, cochlea implants, aneurysm or other clips, metallic-based tattoos or make-up are not normally compatible with MRI. General anesthesia should be preferred over conscious sedation for magnetic resonance imaging and ear protection is necessary for anesthetized patients. Gastroscopy in children should be performed under general anesthesia; and when concluding the procedure, air insufflated into the gastrointestinal tract should be suctioned in all patients. For angiography, maximum monitoring needs to be available to provide hemodynamically unstable patients with adequate anesthesia care; comprehensive radiation protection for patients and staff as well as temperature monitoring for prolonged diagnostic procedures is also necessary. Monitoring oxygen saturation and end-tidal carbon dioxide as well as employing visual and audible alarms is an essential requirement even during conscious sedation. In summary, the number of diagnostic and surgical procedures performed outside the core operating area should be reduced to a minimum and, whenever possible, diagnostic or surgical procedures should be performed within the core operating area.

Analgosedierung mit Remifentanil bei spontan atmenden Patienten für Eingriffe in der interventionellen Radiologie@@@Analgesia with remifentanil in spontaneously breathing patients undergoing brief but painful radiological procedures

INTRODUCTION Percutaneous transhepatic biliary drainage (PTBD) and stenting are very painful procedures in interventional radiology and require potent analgesia; employing remifentanil in spontaneously breathing patients may be one possible strategy. PATIENTS AND METHODS The study group was composed of 18 men and 2 women with a mean age of 63+/-10 (mean+/-SD) years. Pain intensity was measured with a VAS score before the procedure, after local anesthesia on the rib cage, after stenting and after the radiology procedure. RESULTS Remifentanil infusion (dosage: 0.12-0.30 microg/kg body weight/min) was infused throughout the entire radiology procedure according to physical status, past medical history, individual pain, and clinical assessment. During insufflation of 10l O(2)/min via a venturi mask, oxygen saturation did not fall below 96% at any time-point during the procedure. In the VAS score, we noted a decrease after starting the remifentanil infusion towards the end of procedure. All patients were able to move into bed without help. Postoperatively, no analgesics and no antiemetics were needed. CONCLUSIONS Employing a remifentanil infusion for brief interventional radiology procedures in palliative treatment of patients resulted in high patient and radiologist comfort.