G. Pestel

Time course of cerebrovascular autoregulation during extreme Trendelenburg position for robotic-assisted prostatic surgery.

Trendelenburg positioning in combination with pneumoperitoneum during robotic‐assisted prostatic surgery possibly impairs cerebrovascular autoregulation. If cerebrovascular autoregulation is disturbed, arterial hypertension might induce cerebral hyperaemia and brain oedema, while low arterial blood pressure can induce cerebral ischaemia. The time course of cerebrovascular autoregulation was investigated during use of the Trendelenburg position and a pneumoperitoneum for robotic‐assisted prostatic surgery using transcranial Doppler ultrasound. Cerebral blood flow velocity was correlated with arterial blood pressure and the autoregulation index (Mx) was calculated. In 23 male patients, Mx was assessed at baseline, after induction of general anaesthesia, during the Trendelenburg position (40–45°), and after repositioning. During the Trendelenburg position, Mx increased over time, indicating an impairment of cerebrovascular autoregulation. After repositioning, Mx recovered to baseline levels. It can be concluded that with longer durations of Trendelenburg position and pneumoperitoneum, cerebrovascular autoregulation deteriorates, and, therefore, blood pressure management should be adapted to avoid cerebral oedema and the duration of Trendelenburg position should be as short as possible.

Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists

IntroductionSeveral studies have demonstrated that perioperative hemodynamic optimization has the ability to improve postoperative outcome in high-risk surgical patients. All of these studies aimed at optimizing cardiac output and/or oxygen delivery in the perioperative period. We conducted a survey with the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) to assess current hemodynamic management practices in patients undergoing high-risk surgery in Europe and in the United States.MethodsA survey including 33 specific questions was emailed to 2,500 randomly selected active members of the ASA and to active ESA members.ResultsOverall, 368 questionnaires were completed, 57.1% from ASA and 42.9% from ESA members. Cardiac output is monitored by only 34% of ASA and ESA respondents (P = 0.49) while central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents (P < 0.01). Specifically, the pulmonary artery catheter is being used much more frequently in the US than in Europe in the setup of high-risk surgery (85.1% vs. 55.3% respectively, P < 0.001). Clinical experience, blood pressure, central venous pressure, and urine output are the most widely indicators of volume expansion. Finally, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved.ConclusionsIn conclusion, these results point to a considerable gap between the accumulating evidence about the benefits of perioperative hemodynamic optimization and the available technologies that may facilitate its clinical implementation, and clinical practices in both Europe and the United States.

Hemodynamic parameters change earlier than tissue oxygen tension in hemorrhage

BACKGROUND Untreated hypovolemia results in impaired outcome. This study tests our hypothesis whether general hemodynamic parameters detect acute blood loss earlier than monitoring parameters of regional tissue beds. MATERIALS AND METHODS Eight pigs (23-25 kg) were anesthetized and mechanically ventilated. A pulmonary artery catheter and an arterial catheter were inserted. Tissue oxygen tension was measured with Clark-type electrodes in the jejunal and colonic wall, in the liver, and subcutaneously. Jejunal microcirculation was assessed by laser Doppler flowmetry (LDF). Intravascular volume was optimized using difference in pulse pressure (dPP) to keep dPP below 13%. Sixty minutes after preparation, baseline measurements were taken. At first, 5% of total blood volume was withdrawn, followed by another 5% increment, and then in 10% increments until death. RESULTS After withdrawal of 5% of estimated blood volume, dPP increased from 6.1% +/- 3.0% to 20.8% +/- 2.7% (P < 0.01). Mean arterial pressure (MAP), mean pulmonary artery pressure (PAP) and pulmonary artery occlusion pressure (PAOP) decreased with a blood loss of 10% (P < 0.01). Cardiac output (CO) changed after a blood loss of 20% (P < 0.05). Tissue oxygen tension in central organs, and blood flow in the jejunal muscularis decreased (P < 0.05) after a blood loss of 20%. Tissue oxygen tension in the skin, and jejunal mucosa blood flow decreased (P < 0.05) after a blood loss of 40% and 50%, respectively. CONCLUSIONS In this hemorrhagic pig model systemic hemodynamic parameters were more sensitive to detect acute hypovolemia than tissue oxygen tension measurements or jejunal LDF measurements. Acute blood loss was detected first by dPP.

Noninvasive Hemodynamic Measurements During Neurosurgical Procedures in Sitting Position

Background: Neurosurgical procedures in sitting position need advanced cardiovascular monitoring. Transesophageal echocardiography (TEE) to measure cardiac output (CO)/cardiac index (CI) and stroke volume (SV), and invasive arterial blood pressure measurements for systolic (ABPsys), diastolic (ABPdiast) and mean arterial pressure (MAP) are established monitoring technologies for these kind of procedures. A noninvasive device for continuous monitoring of blood pressure and CO based on a modified Penaz technique (volume-clamp method) was introduced recently. In the present study the noninvasive blood pressure measurements were compared with invasive arterial blood pressure monitoring, and the noninvasive CO monitoring to TEE measurements. Methods: Measurements of blood pressure and CO were performed in 35 patients before/after giving a fluid bolus and a change from supine to sitting position, start of surgery, and repositioning from sitting to supine at the end of surgery. Data pairs from the noninvasive device (Nexfin HD) versus arterial line measurements (ABPsys, ABPdiast, MAP) and versus TEE (CO, CI, SV) were compared using Bland-Altman analysis and percentage error. Results: All parameters compared (CO, CI, SV, ABPsys, ABPdiast, MAP) showed a large bias and wide limits of agreement. Percentage error was above 30% for all parameters except ABPsys. Conclusion: The noninvasive device based on a modified Penaz technique cannot replace arterial blood pressure monitoring or TEE in anesthetized patients undergoing neurosurgery in sitting position.

Comparison of the gold standard of hemoglobin measurement with the clinical standard (BGA) and noninvasive hemoglobin measurement (SpHb) in small children: a prospective diagnostic observational study

Collecting a blood sample is usually necessary to measure hemoglobin levels in children. Especially in small children, noninvasively measuring the hemoglobin level could be extraordinarily helpful, but its precision and accuracy in the clinical environment remain unclear. In this study, noninvasive hemoglobin measurement and blood gas analysis were compared to hemoglobin measurement in a clinical laboratory.

Cerebral oxygen saturation and cardiac output during anaesthesia in sitting position for neurosurgical procedures: a prospective observational study

BACKGROUND Neurosurgical operations in the dorsal cranium often require the patient to be positioned in a sitting position. This can be associated with decreased cardiac output and cerebral hypoperfusion, and possibly, inadequate cerebral oxygenation. In the present study, cerebral oxygen saturation was measured during neurosurgery in the sitting position and correlated with cardiac output. METHODS Perioperative cerebral oxygen saturation was measured continuously with two different monitors, INVOS® and FORE-SIGHT®. Cardiac output was measured at eight predefined time points using transoesophageal echocardiography. RESULTS Forty patients were enrolled, but only 35 (20 female) were eventually operated on in the sitting position. At the first time point, the regional cerebral oxygen saturation measured with INVOS® was 70 (sd 9)%; thereafter, it increased by 0.0187% min-1 (P<0.01). The cerebral tissue oxygen saturation measured with FORE-SIGHT® started at 68 (sd 13)% and increased by 0.0142% min-1 (P<0.01). The mean arterial blood pressure did not change. Cardiac output was between 6.3 (sd 1.3) and 7.2 (1.8) litre min-1 at the predefined time points. Cardiac output, but not mean arterial blood pressure, showed a positive and significant correlation with cerebral oxygen saturation. CONCLUSIONS During neurosurgery in the sitting position, the cerebral oxygen saturation slowly increases and, therefore, this position seems to be safe with regard to cerebral oxygen saturation. Cerebral oxygen saturation is stable because of constant CO and MAP, while the influence of CO on cerebral oxygen saturation seems to be more relevant. CLINICAL TRIAL REGISTRATION NCT01275898.

Aspects of perioperative care in patients with diabetes

Diabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.ZusammenfassungDiabetes mellitus ist in Deutschland eine Volkskrankheit. Aufgrund der diabetischen Folgeerkrankungen (Makroangiopathie, Mikroangiopathie und Neuropathie) bedürfen Diabetespatienten einer intensiveren anästhesiologischen Betreuung in der perioperativen Phase im Vergleich zu Nichtdiabetespatienten. Eine sorgfältige, ausführliche Anamnese mit Erfassung des diabetesbedingten perioperativen Gefährdungspotenzials (Herz-Kreislauf-Erkrankungen, Gastroparese, Neuropathie, „Stiff-joint“-Syndrom) hat nach derzeitigem Wissensstand wahrscheinlich größere Bedeutung als eine spezifische Medikamenten- oder Verfahrenswahl. Das intraoperative anästhesiologische Management diabeteskranker Patienten fokussiert sich in besonderem Maß auf die Erhaltung der hämodynamischen Stabilität, perioperative Infektionsprophylaxe und Kontrolle der Glucosehomöostase. Wurde noch vor einigen Jahren das Erzwingen einer strikten Normoglykämie mithilfe forcierter Insulintherapie propagiert, erkennen neuere Studien hierin ein Risikopotenzial. Die optimierte perioperative Behandlung von Diabetespatienten sollte daher den gewünschten Blutzuckerspiegel klar benennen, bewährte Therapiealgorithmen vorhalten und eine engmaschige Überwachung mit ggf. umgehender Modifikation der Behandlung ermöglichen.AbstractDiabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.

Aspekte der perioperativen Behandlung von Diabetespatienten

Diabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.ZusammenfassungDiabetes mellitus ist in Deutschland eine Volkskrankheit. Aufgrund der diabetischen Folgeerkrankungen (Makroangiopathie, Mikroangiopathie und Neuropathie) bedürfen Diabetespatienten einer intensiveren anästhesiologischen Betreuung in der perioperativen Phase im Vergleich zu Nichtdiabetespatienten. Eine sorgfältige, ausführliche Anamnese mit Erfassung des diabetesbedingten perioperativen Gefährdungspotenzials (Herz-Kreislauf-Erkrankungen, Gastroparese, Neuropathie, „Stiff-joint“-Syndrom) hat nach derzeitigem Wissensstand wahrscheinlich größere Bedeutung als eine spezifische Medikamenten- oder Verfahrenswahl. Das intraoperative anästhesiologische Management diabeteskranker Patienten fokussiert sich in besonderem Maß auf die Erhaltung der hämodynamischen Stabilität, perioperative Infektionsprophylaxe und Kontrolle der Glucosehomöostase. Wurde noch vor einigen Jahren das Erzwingen einer strikten Normoglykämie mithilfe forcierter Insulintherapie propagiert, erkennen neuere Studien hierin ein Risikopotenzial. Die optimierte perioperative Behandlung von Diabetespatienten sollte daher den gewünschten Blutzuckerspiegel klar benennen, bewährte Therapiealgorithmen vorhalten und eine engmaschige Überwachung mit ggf. umgehender Modifikation der Behandlung ermöglichen.AbstractDiabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.

Höchstmaß an klinischer Kompetenz bei endovaskulären Eingriffen@@@Highest level of clinical competence for endovascular interventions

Im Jahr 2014 verstarben in Deutschland 868.356 Personen. Wie in den vorigen Jahren war auch 2014 eine Erkrankung des Kreislaufsystems mit knapp 40% die häufigste Todesursache. Erkrankungen des Herzens und der Gefäße sind naturgemäß v. a. Erkrankungen bei älteren Menschen. Im Jahr 2014 waren 92% der an Erkrankungen des Kreislaufsystems Verstorbenen 65 Jahre und älter [10]. Die Anzahl der Menschen im Alter ab 65 Jahren wird in den nächsten Jahrzehnten absolut und relativ weitersteigen. Besonders stark wachsen wird diese Altersgruppe in den nächsten 20 Jahren durch den Eintritt der sog. Babyboomer ins Rentenalter. Während derzeit jede fünfte Person der Altersgruppe über 65 Jahren angehört, wird es 2060 jede dritte sein. Die Anzahl der über 80-Jährigen wird 2060 etwa doppelt so hoch sein wie heute: Vier von 10 Menschen im Alter ab 65 Jahren werden dann 80 Jahre und älter sein [11]. Die anästhesiologische Versorgung betagter Patientinnen und Patienten mit Herzund/oder Gefäßerkrankungen wird unseren Berufsalltag zunehmend prägen. Große periphere Gefäßeingriffe und Aortenchirurgie sind mit einem hohen kardialen Risiko behaftet [2]. Die v. a. bei offenerChirurgieauftretendenIschämieReperfusion-Phänomene können nicht nur zuunmittelbarenhämodynamischen Verwerfungen, sondernauchzunachhaltigen Störungen durch Mediatorfreisetzung und Veränderung der Kapillarpermeabilität führen und erfordern daher die gesamte Aufmerksamkeit geschulter Anästhesisten.

Höchstmaß an klinischer Kompetenz bei endovaskulären Eingriffen

Im Jahr 2014 verstarben in Deutschland 868.356 Personen. Wie in den vorigen Jahren war auch 2014 eine Erkrankung des Kreislaufsystems mit knapp 40% die häufigste Todesursache. Erkrankungen des Herzens und der Gefäße sind naturgemäß v. a. Erkrankungen bei älteren Menschen. Im Jahr 2014 waren 92% der an Erkrankungen des Kreislaufsystems Verstorbenen 65 Jahre und älter [10]. Die Anzahl der Menschen im Alter ab 65 Jahren wird in den nächsten Jahrzehnten absolut und relativ weitersteigen. Besonders stark wachsen wird diese Altersgruppe in den nächsten 20 Jahren durch den Eintritt der sog. Babyboomer ins Rentenalter. Während derzeit jede fünfte Person der Altersgruppe über 65 Jahren angehört, wird es 2060 jede dritte sein. Die Anzahl der über 80-Jährigen wird 2060 etwa doppelt so hoch sein wie heute: Vier von 10 Menschen im Alter ab 65 Jahren werden dann 80 Jahre und älter sein [11]. Die anästhesiologische Versorgung betagter Patientinnen und Patienten mit Herzund/oder Gefäßerkrankungen wird unseren Berufsalltag zunehmend prägen. Große periphere Gefäßeingriffe und Aortenchirurgie sind mit einem hohen kardialen Risiko behaftet [2]. Die v. a. bei offenerChirurgieauftretendenIschämieReperfusion-Phänomene können nicht nur zuunmittelbarenhämodynamischen Verwerfungen, sondernauchzunachhaltigen Störungen durch Mediatorfreisetzung und Veränderung der Kapillarpermeabilität führen und erfordern daher die gesamte Aufmerksamkeit geschulter Anästhesisten.