P. Kessler

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version.

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2nd Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006–2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade “A” (very strong recommendation), Grade “B” (strong recommendation) and Grade “0” (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3rd Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.

Inhibition of Inducible Nitric Oxide Synthase Restores Endothelium-Dependent Relaxations in Proinflammatory Mediator-Induced Blood Vessels

Endothelium-dependent relaxations mediated by nitric oxide (NO) are attenuated in arteries exposed to proinflammatory mediators. Because proinflammatory mediators stimulate the expression of the inducible NO synthase (iNOS) in vascular cells, the role of iNOS-derived NO in the impaired endothelium-dependent relaxation was examined in arterial ring preparations. Exposure of rabbit carotid arteries to interleukin-1 beta (IL-1 beta; 100 U/mL for 7 hours) and porcine coronary arteries to a combination of tumor necrosis factor-alpha (1000 U/mL), interferon-gamma (500 U/mL), and lipopolysaccharide (10 micrograms/mL) for 15 hours (conditions that are associated with iNOS expression) markedly attenuated relaxations to receptor-dependent agonists, whereas those to the calcium ionophore A23187 and sodium nitroprusside were virtually unchanged. The impaired relaxation was not associated with a reduced level of the constitutive endothelial NOS (cNOS) but was accompanied by a reduced formation of biologically active NO as assessed in a bioassay system. The attenuated relaxation of carotid arteries to acetylcholine was not affected by superoxide dismutase and was neither found in arteries exposed to IL-1 beta for only 15 minutes nor in IL-1 beta-treated arteries for 7 hours followed by a 17-hour incubation period without the cytokine. Furthermore, no impaired relaxation was found in rings exposed to IL-1 beta in combination with either cycloheximide or N-alpha-tosyl-L-lysine chloromethyl ketone or pyrrolidine dithiocarbamate, treatments that prevent iNOS expression. In addition, selective inhibition of iNOS with S-methylisothiourea (10 mumol/L) completely restored acetylcholine-induced relaxations. These findings indicate that the continuous generation of NO induced by proinflammatory mediators plays a major role in the inhibition of endothelium-dependent relaxation, most likely by impairing a step in the signal transduction cascade that links activation of endothelial receptors to the calcium-calmodulin-dependent activation of NOS.

Prophylactically-administered rectal acetaminophen does not reduce postoperative opioid requirements in infants and small children undergoing elective cleft palate repair.

Rectal acetaminophen (Ac) is often administered prophylactically at anesthesia induction for postoperative pain management in small children and is thought to have an opioid-sparing effect. We assessed in this double-blinded, prospective, randomized study early opioid requirements after three doses of Ac (10, 20, and 40 mg/kg versus placebo) in 80 children (ASA physical status I, age 11.4 ± 9.9 mo) undergoing cleft palate repair. Single Ac plasma concentrations were measured. Pain scores assessed in the postanesthesia care unit of ≥4 of 10 resulted in the IV administration of 25 &mgr;g/kg piritramide, a popular European &mgr; receptor agonist (lockout time, 10 min; maximum 0.125 mg/kg). There were no significant differences between groups with regard to the early postoperative pain scores and the overall cumulative IV opioid requirements. Maximal plasma concentrations achieved were only subtherapeutic (Ac 10 mg/kg: 8 &mgr;g/mL; Ac 20 mg/kg: 13 &mgr;g/mL; Ac 40 mg/kg: 21 &mgr;g/mL after 122, 122, and 121 min, respectively). We conclude that rectal Ac up to 40 mg/kg has no opioid-sparing effect, does not result in analgesic Ac plasma concentrations, and lacks proof of its efficacy in infants and small children undergoing cleft palate repair, whereas titrated IV opioid boluses produced rapid and reliable pain relief.

Single-dilator percutaneous tracheostomy: a comparison of PercuTwist and Ciaglia Blue Rhino techniques

AbstractObjective. To compare two single-dilator percutaneous tracheostomy techniques, Ciaglia Blue Rhino and the new PercuTwist technique. Design and setting. Randomized, observational clinical trial in patients undergoing elective percutaneous tracheostomy in the intensive care units of a university hospital. Patients. Seventy consecutive, adult patients undergoing either Blue Rhino (n=35) or PercuTwist tracheostomy (n=35). Interventions. Performance of percutaneous tracheostomy with a novel screwlike dilating device (PercuTwist) or conically shaped, flexible rubber dilator (Blue Rhino). Results. Stoma dilation was successful with the respective device in all patients. While subsequent tracheostomy cannula insertion was uneventful in all but one patients undergoing the Blue Rhino technique, it was difficult or even impossible in eight patients who underwent PercuTwist tracheostomy. Regarding serious and intermediate procedural-related complications, two cases of posterior tracheal wall injury occurred with the PercuTwist technique. No serious or intermediate complications were noted during Blue Rhino tracheostomy. There was no statistical significance between the two techniques in terms of minor and overall complications. Conclusions. So far the new PercuTwist technique represents an alternative to the established Blue Rhino technique. Nonetheless, the two cases of posterior tracheal wall injury should not be underestimated, on the one hand, but, on the other, may be attributed to a learning curve with a new technique. The new PercuTwist technique should be performed by various teams and in a considerably larger numbers of patients before an ultimate rating can be made.

Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment

IntroductionThis open label, multicentre study was conducted to assess the times to offset of the pharmacodynamic effects and the safety of remifentanil in patients with varying degrees of renal impairment requiring intensive care.MethodsA total of 40 patients, who were aged 18 years or older and had normal/mildly impaired renal function (estimated creatinine clearance ≥ 50 ml/min; n = 10) or moderate/severe renal impairment (estimated creatinine clearance <50 ml/min; n = 30), were entered into the study. Remifentanil was infused for up to 72 hours (initial rate 6–9 μg/kg per hour), with propofol administered if required, to achieve a target Sedation–Agitation Scale score of 2–4, with no or mild pain.ResultsThere was no evidence of increased offset time with increased duration of exposure to remifentanil in either group. The time to offset of the effects of remifentanil (at 8, 24, 48 and 72 hours during scheduled down-titrations of the infusion) were more variable and were statistically significantly longer in the moderate/severe group than in the normal/mild group at 24 hours and 72 hours. These observed differences were not clinically significant (the difference in mean offset at 72 hours was only 16.5 min). Propofol consumption was lower with the remifentanil based technique than with hypnotic based sedative techniques. There were no statistically significant differences between the renal function groups in the incidence of adverse events, and no deaths were attributable to remifentanil use.ConclusionRemifentanil was well tolerated, and the offset of pharmacodynamic effects was not prolonged either as a result of renal dysfunction or prolonged infusion up to 72 hours.

Incidence of gastrointestinal complications in cardiopulmonary bypass patients

Gastrointestinal complications after cardiac surgery are associated with a high mortality rate. Because of the absence of early specific clinical signs, diagnosis is often delayed. The present study seeks to determine predictive risk factors for subsequent gastrointestinal complications after cardiosurgical procedures. Within a 1-year period, a total of 1116 patients who had undergone open heart surgery with cardiopulmonary bypass were prospectively studied for gastrointestinal complications. To determine predictive factors, all case histories of the patients were analyzed. Of the 1116 patients, 23 (2.1%) had gastrointestinal complications during the postoperative period, 10 of whom had to undergo subsequent abdominal surgery. Of these 23 patients, 20 died. Early gastrointestinal complications, which occurred mostly on postoperative days 6 or 7, consisted of bowel ischemia or hepatic failure. Late complications were gastrointestinal bleeding, pseudomembranous colitis, cholecystitis, and septic rupture of a spleen. The relative risk for abdominal complications after cardiopulmonary bypass was highly increased in association with (1) a cardiac index less than 2.0 l/min−1/(m2)−1, (2) postoperative onset of atrial fibrillation, (3) emergency surgery, (4) need for vasopressors, (5) need for intraaortic balloon counterpulsation, and (6) need for early redo thoracotomy due to surgical complications. All patients with necrotic bowel disease had elevated serum lactate levels. Furthermore, cardiopulmonary bypass and aortic clamping times were significantly prolonged in patients who developed gastrointestinal complications. A number of predictive factors contribute to the development of gastrointestinal complications after cardiopulmonary bypass surgery. Knowledge of these factors may lead to earlier identification of patients at increased risk and may allow more efficient and earlier interventions to reduce mortality.RésuméObjectifs: Les complications gastro-intestinales après chirurgie cardiaque sont associéesà un taux de mortalité élevé. Le diagnostic en est souvent retardé en raison de I’absence de signes cliniques spécifiques, précoces. Cette étude chercheà déterminer les facteurs de risque prédictifs de complications gastrointestinales après chirurgie cardio-vasculaire. Méthodes: Pendant une période d’un an, 1116 patients au total ayant eu une intervention chirurgicaleà coeur ouvert avec shunt cardiopulmonaire ont été étudiés prospectivement dans` la recherche de complications gas tro-intestinales. Afin de déterminer les facteurs prédictifs, tous les antécédents ont é té analysés. Résultats: 23 (2.1%) des 1116 patients ont eu des complications gastrointestinales pendant la période postopératoire, dont 10 qui ont nécessité un acte chirurgical abdominal. Parmi ces 23 patients, 20 sont décédés. Des complications gastro-intestinales précoces sont survenues aux jours postopératoires 6 ou 7, sous forme d’ischémie intestinale ou d’insuffisance hepatique. Les complications tardives ont été I’hémorragie gastro-intestinale, la colite pseudomembraneuse, la cholécystite et un cas de rupture septique de la rate. Le risque relatif de faire des complications abdominales après shunt cardio-pulmonaire était plus important lorsque le patient: (1) avait un indexe cardiaque inférieurà 2,0 l/min−1/ (m2)−1, (2) a prése nté une fibrillation auriculaire postopératoire, (3) a eu besoin d’une intervention en urgence, (4) a eu besoin de vasopresseurs, (5) a nécessité I’utilisation d’un ballonnetà contrepression, et (6) a eu une re-thoracotomie précoce en raison des complications. Tous les patients ayant une nécrose intestinale avaient des taux de lactates élevés dans le sérum. Les temps de shunt cardio-pulmonaire et de clampage aortique ont été prolongés de façon significative chez les patients qui ont développé des complications gastro-intestinales. Conclusions: II existe un certain nombre de facteurs prédictifs qui peuvent contribuer au développement des complications gastrointestinales après un shunt cardio-pulmonaire. La connaissance de ces facteurs pourrait aiderà identifier ces patientsà risque et pourrait permettre une intervention plus efficace et plus précoce, réduisant ainsi la mortalité.ResumenObjetivo: Las complicaciones gastrointestinales tras cirugía cardiaca conllevan una alta tasa de mortalidad. Debido a la ausencia de signos clinico precoces, el diagnóstico, con frecuenci à, se retrasa. El presente estudio pretende averiguar los factores que permitan predecir el riesgo de padecer complicaciones gastrointestinales tras cirugía cardiaca. Métodos: Durante un anõ se estudiaron prospectivamente las complicaciones gastrointestinales de 1,116 pacientes intervenidos a corazón abierto con derivación cardio-pulmonar. Se analizaron las historias clínicas de todos los pacientes con objeto de averiguar los factores predictivos. Resultados: En 23 (2.1%) de los 1,116 pacientes se produjeron complicaciones gastrointestinales en el periodo postoperatorio, requiriendo 10 de ellos tratamiento quirúrgico. De los 23 pacientes, 20 fallecieron. Las complicaciones gastrointestinales precoces aparecieron entre el 6, 7 dias del postoperatorio, tratándose de isquemia intestinal o fracaso hepático. Las complicaciones tardias fueron: hemorragia gastrointestinal, colitis pseudo-membranosa, colecistitis y ruptura séptica del bazo. El riesgo de desarrollar complicaciones abdominales, tras derivación cardio-pulmonar se incrementa cuando se producen: (1) índice cardiaco menor a 2.0 l/min−1/ (m2)−1, (2) crisis postoperatorias de fibrilación atrial, (3) cirug ía de urgencia, (4) utilización de vasopresores, (5) empleo del balón intraaórtico de contrapulsación y (6) retoracotomía precoz por complicaciones quirúrgicas. Todos los pacientes con afectación necrótica intestinal presentaron niveles altos de la concentración sérica de lactato. Además, en los pacientes que desarrollaron complicaciones gastrointestinales, tanto el tiempo de derivación cardio-pulmonar como el del clampado de aorta fueron significativamente más prolongados. Conclusiones: Se describen diversos factores predictivos que contribuyen al desarrollo de complicaciones gastrointestinales tras cirugía cardiaca con derivación cardio-pulmonar. El conocimiento de los mismos, permitirá la identificación precoz de los pacientes de mayor riesgo, pudiéndose así realizar intervenciones más precoces y eficaces que reduzcan la mortalidad.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.

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.

Effects of prolonged pneumoperitoneum on hemodynamics and acid-base balance during totally endoscopic robot-assisted radical prostatectomies.

Laparoscopic techniques have become a standard approach for diagnostic and therapeutic procedures in many surgical disciplines. Recent progress in endoscopic surgery is based on the integration of computer-enhanced telemanipulation systems. Because robot-assisted radical prostatectomies take up to 10 hours, the present study was performed to evaluate the effects of prolonged intraperitoneal CO2 insufflation on hemodynamics and gas exchange in 15 patients with prostate cancer. When CO2 insufflation was initiated, peak inspiratory pressure increased and reached significant values after a 1.5-hour period of intraperitoneal CO2 insufflation. With the release of CO2, peak inspiratory pressure decreased close to baseline values. A significant increase in heart rate was observed after a 4-hour period of increased intraabdominal pressure. Mean arterial blood pressure and central venous pressure remained stable during CO2 insufflation. Minute ventilation was adjusted according to repeated blood gas analyses to maintain pH, base excess (BE), bicarbonate (HCO3−), and PaCO2 within physiologic ranges. The present data show, that prolonged CO2 insufflation during totally endoscopic robot-assisted radical prostatectomy results in only minor changes in hemodynamics and acid-base status. Because of the limited experience with long-term pneumoperitoneum, we consider invasive haemodynamic monitoring and repeat blood gas analysis essential for such operations.RésuméLa technique laparoscopique est devenue le standard pour beaucoup de procédés diagnostiques et thérapeutiques dans diverses disciplines chirurgicales. De progrès récents en chirurgie endoscopique sont basés sur l’intégration de systèmes de la télémanipulation sur ordinateur. Puisque à présent, les prostatectomies radicales assistées par robot peuvent durer jusqu’à 10 heures, cette étude a été entreprise pour évaluer les effets de l’insufflation intrapéritonéale prolongée par le CO2 sur l’hémodynamique et les échanges gazeux chez 15 patients porteurs de cancer de la prostate. Au début de l’insufflation par le CO2, la pression inspiratoire maximale a augmenté et a atteint des valeurs significatives après 1.5 heures d’insufflation intrapéritonéale. Lorsque l’on a arrêté l’insufflation par le CO2, la pression inspiratorie maximale a diminué pour se rapprocher des valeurs de base. On a observé une augmentation significative de la fréquence cardiaque après 4 heures d’hyperpression intra-abdominale. La pression artérielle moyenne et la pression veineuse centrale sont restées stables pendant l’insufflation par le CO2. La ventilation minute a été ajustée selon les analyses des gaz du sang répétées pour maintenir le pH, la base-excès, les taux de HCO3− et de PaCO2 dans les limites de la normale. Nos données actuelles nous montrent que l’insufflation prolongée de CO2 pendant la prostatectomie radicale endoscopique assistée par robot ne modifie que peu l’état hémodynamique et l’équilibre acido-basique. En raison d’une expérience limitée en ce qui concerne le pneumopéritoine prolongé, nous considérons que le monitorage hémodynamique invasif et l’analyse répétée des gaz du sang sont essentiels pour de telles opérations.ResumenEn muchas especialidades quirúrgicas las técnicas laparoscópicas se han convertidomen en procedimientos estándar tanto con fines diagnósticos como terapéuticos. Progresos recientes han permitido integrar la cirugía endoscópica en sistemas computarizados propiciando las técnicas de telecirugía y telemanipulación. Dado que la prostatectomía radical con ayuda de un robot dura más de 10 horas, estudiamos los efectos de un neumoperitoneo prolongado con CO2 en la hemodinamia e intercambio gaseoso en 15 pacientes con cáncer de próstata. Al iniciar la insuflación de CO2 la presión inspiratoria aumenta y alcanza valores significativos a las 1–5 horas de la instauración del neumoperitoneo. Cuando éste desaparece la presión inspiratoria máxima desciende a nivel basai. La presión arterial media (MAP) y la venosa central (PVC) se mantienen estables durante el neumoperitoneo. La ventilación minuto ha de ajustarse de acuerdo con gasometrías repetidas para mantener dentro de límites normales el pH, BE, HCQ3− y la PaCO2. Nuestros hallazgos demuestran que el neumoperitoneo prolongado por prostatectomía radical asistida mediante un robot produce cambios mínimos hemodinámicos y del equilibro ácido-base. Dada la corta experiencia con neumoperitoneo de larga duración, en estas operaciones son obligatorios la monitorización invasiva hemodinámica y frecuentes análisis gasométricos.

Postoperative Schmerztherapie im Kindesalter : Ergebnisse einer repräsentativen Umfrage in Deutschland

ZusammenfassungDie letzte anästhesiologische Repräsentativerhebung zur postoperativen Schmerztherapie in Deutschland stammt aus dem Jahre 1987, differenzierte Daten zur postoperativen Schmerztherapie im Kindesalter fehlen bisher. Ziel unserer Umfrage war es, den Status quo der postoperativen Schmerztherapie im Kindesalter in deutschen anästhesiologischen Kliniken im Jahre 2000 zu erfassen. An anästhesiologische Abteilungen und interdisziplinäre Intensivstationen (n=1.500) deutscher Krankenhäuser wurde ein detaillierter Fragebogen zur aktuellen Praxis der postoperativen Schmerztherapie im Kindesalter versendet. Die Rücklaufquote betrug 42,6%. Rektal appliziertes Paracetamol ist das Standardmedikament in der postoperativen Schmerztherapie im Kindesalter, Opioide werden im Vergleich zu früheren Untersuchungen vermehrt eingesetzt. Nichtsteroidale Antiphlogistika und Spasmolytika spielen ebenso wie Regionalanästhesietechniken in der postoperativen Schmerztherapie im Kindesalter eine untergeordnete Rolle. Im europäischen Vergleich werden neuere Methoden wie die patienten- oder elternkontrollierte Analgesie in Deutschland häufiger eingesetzt. Trotz moderner Organisationskonzepte und einer Vielzahl von angewandten Substanzen halten 71,7% der Anästhesisten die postoperative Schmerztherapie im Kindesalter für verbesserungswürdig.AbstractThe last survey addressing postoperative pain management in Germany was published in 1987, special data concerning postoperative pain management in pediatric patients had not been presented previously. The goal of this survey is to present the standard of postoperative pain management in pediatric patients in Germany. A detailed questionnaire was mailed to all German anaesthesia departments and interdisciplinary intensive care units (n=1,500) to determine the current management of postoperative pain management in pediatric patients. After eight weeks, 42.6% of the survey had been returned. Rectally administered acetaminophen is the standard drug regimen for postoperative analgesia in children. Compared to previous surveys, the use of opioids has increased in popularity. The routine use of non-steroid antiinflammatory drugs (NSAIDs) and spasmolytics as well as the application of regional anaesthesia techniques is uncommon in pediatric postoperative pain management. Compared to other European countries, patient- or parent-controlled analgesia is more popular in Germany. Despite modern concepts of organization and a great variety of drugs available today, 71.1% of the responding anesthesiologists in this survey still believe that pediatric postoperative pain management needs to be improved.

Awake coronary artery bypass grafting: utopia or reality?

BACKGROUND Off-pump coronary artery bypass grafting (OPCAB) was implemented to reduce trauma during surgical coronary revascularization. High thoracic epidural anesthesia further reduced intraoperative stress and postoperative pain. This technique also supports awake coronary artery bypass (ACAB), completely avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients. We compared our first results of the ACAB procedure with the conventional OPCAB operation. METHODS Thirty-five patients underwent ACAB (group A) with left internal mammary artery to left anterior descending coronary artery grafting using a partial lower ministernotomy (n = 25) or double bypass grafting (n = 9) and even triple vessel coronary artery revascularization (n = 1) through complete median sternotomy. Thirty-four patients (group B), matched for age, sex, and comorbidity with group A, underwent either partial lower ministernotomy (n = 24) or OPCAB by complete sternotomy (n = 10). We recorded clinical outcomes and postoperative visual analog scale pain scores. RESULTS In group A, 32 patients remained awake throughout the entire procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Patients in group A had a recovery room stay of 6.0 +/- 3.2 hours. In group B, mechanical ventilation was implemented for 4.8 +/- 3.1 hours and intensive care unit stay lasted 12 +/- 6.8 hours. Group A had no in-hospital deaths, compared with 1 death in the conventional OPCAB group. Each group had 1 patient with graft stenosis detected on the predischarge angiogram. Early postoperative pain was significantly less in group A than in group B (visual analog scale of 32 +/- 8 compared with 58 +/- 11, p < 0.0001). CONCLUSIONS The present data demonstrate the feasibility and safety of surgical coronary revascularization without general anesthesia. Continuation of thoracic epidural analgesia provides better pain control and faster mobilization after such procedures. Surprisingly, the ACAB procedure was well accepted by the patients.