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Rapid progress in medical science and technique offer new complex individual treatment modalities. Distinct profile qualifications like echocardiography, electroencephalography are required for anesthesia in high risk populations (cardiovascular, pediatric and neuro surgical patients) to guarantee best patient care and outcome. Accredited subspecialties and distinct fellowship programs are required to improve medical education, training and research., (© Georg Thieme Verlag Stuttgart · New York.)

Emergence Delirium in children after general anesthesia is a common and self limitating event. Although it might be seen as being harmless it can cause other serious complications and might leave both parents and other caregivers with a negative impression behind. Although the cause may still not be clear, potential predictors can be named: preschool age, the use of fast acting volatile anesthestics, higher preoperative anxiety levels and postoperative pain.A child-focused approach to reduce preoperative anxiety focusing on distraction methods rather than pharmacological sedation may be the key as well as sufficient postoperative pain control and the use of total intravenous anesthesia. Parenteal presence during induction of anaesthesia (PPIA) may be beneficial to reduce preoperative anxiety levels, but has failed to prove a better outcome regarding ED.The use of age adopted scores/scales to diagnose ED and Pain are mandatory.In the case of an ED event it is most important to protect the child from self injury and the loss of the iv-line. Postoperative pian needs to be ruled out before treating ED. Most cases can be treated by interrupting the situation and putting the child "back to sleep". Short acting drugs as Propofol have been used successfully due to its pharmacodynamics and short acting profile. Alternatively alpha-agonists or ketamin may be preferred by other authors. If potential predictors and a positive history are present, prophylactic treatment should be considered. A TIVA or the use of alpha-2-agonists have proven to be successful in reducing the risk of an ED. Midazolam may reduce preoperative anxiety but not the incidence of ED and should therefore be used carefully and is not a good choice in PACU for the treatment of ED.Parents who witnessed ED in their children should be guided and followed up. Explaining this phenomenon to parents beforehand should be part of the pre anaesthesia clinic talk and written consent.Standard protocols should be in place for treatment in the postoperative period., (© Georg Thieme Verlag Stuttgart · New York.)

There are about 6000 children with congenital heart diseases (CHD) born in Germany each year. This number is constant irrespective of the improving prenatal diagnostics. As many of the surgically treated patients now reach adulthood, due to the development of treatments and operations for CHD, there is an increasing likelihood that surgically treated patients with CHD come to be treated in non-specialized hospitals at any time. Furthermore, it enables anesthesiologists, who have not so much opportunities to treat patients with CHD, to handle such patients safely and successfully, when further knowledge of underlying heart failure and related pathophysiologic characteristics are known. The purpose of this article is to achieve a respectful and confident treatment for patients who had corrective or palliative operations for CHD., (© Georg Thieme Verlag Stuttgart · New York.)

The Helsinki Declaration offers guidelines for the warranty and improvement of patient safety in Anaesthesiology. The assessment of elective patients and their preoperative optimization plays a key role herein. Individual risk factors and preexisting pathologies have to be identified in order to initiate specific pre- and aftercare and an appropriate monitoring. The measures need to be evidence-based, goal-oriented and efficient. Our recommendations aim at elective adult patients planned for non-cardiac and non-lung-resecting surgery and stress the importance of gathering information from patients, performing physical examinations and arranging further diagnostic customized upon these findings only in contrast to routine testing. They shall spark the formulation or improvement of center-based, interdisciplinary standards of procedure in order to fulfill our great responsibility for the perioperative care of our patients., (© Georg Thieme Verlag Stuttgart · New York.)

At present, providers at an Anesthesia Preoperative Evaluation Clinic (APEC) may have difficulties in gaining access to relevant clinical information, including external medical records, surgical dictations etc. This common occurence makes obtaining an informed consent by the patient after a complete pre-anesthetic assessment difficult. This form of patient information is subject to wide interindividual variations and, thus, represents a challenge for quality assurance. Insufficient or not completed pre-anesthetic assessments can lead to an untimely termination of an elective procedure.A web-based pre-anesthetic evaluation record moves the time point of the first contact to well before the day of admission. The current pre-anesthesia evaluation record is replaced by a structured interview in the form of a complex of questions in a specific hierarchy taking guidelines, standard operating procedures (SOP) and evidence-based medicine (EBM) into consideration. The answers to the complex of questions are then classified according to agreed criteria and possible scoring systems of relevant classifications. The endpoints result in procedural recommendations not only for the informing anesthesiologist but also for the patient. The standardized risk criteria can be used as core process indicators to check the process quality of the anesthesiological risk evaluation. Short-notice cancellations of elective operations due to incomplete premedication procedures will then be avoided with the help of such structured and evidence-based patient interviews with detailed assessment of the anesthesiological risk profile.The web-based anesthesia evaluation record (WAR) corresponds with the recommendations of the DGAI to carry out the staged information in analogy to the staged information of Weissauer. The basic practice is not changed by WACH. By means of WACH, the time point of the first contact with anesthesia is moved forward and occurs within a different framework. WACH has potential advantages for both patient and anesthesiologist, not least due to a higher patient safety., (© Georg Thieme Verlag Stuttgart · New York.)

Patients, general public and health insurance funds focus more and more on the quality of medical performance. Anaesthesia related severe morbidity and mortality are unsuitable to judge the quality of an anaesthesia procedure. Other aspects like rapid and comfortable postoperative recovery or satisfaction of the patients with the anaesthesia procedure experience therefore rising attention. With this critical review we aim to give support for appraisal of already published studies and for design and realization of future trials.

Both, obligatory non-invasive hemodynamic monitoring and adjunctive hemodynamic monitoring need to be considered perioperatively. Patient as well as surgical requirements may contribute to the decision making process. Effectiveness and quality of the perioperative patient monitoring solely depends on the knowledge and awareness of the anesthesist with regard to the potentials and limitations of the applied monitoring.

The S2e Guidelines for sedation practice of the German Society for Anaesthesiology and Intensive Care recommend a clear prior definition of depth of sedation to be achieved in a given case, monitoring of depth of sedation by means of scoring systems, appropriate selection of analgesics and sedatives and the use of patient-oriented treatment regimens. These measures not only reduce significantly length of artificial respiration, length of time spent on the intensive care unit and overall length of stay in the hospital but also the frequency of complications. Therefore, implementation of the Guidelines will result in significant reductions in costs in a given case. This is a decisive economic benefit for any hospital working under the restraints of the DRG system.

Several reasons such as ignorance, convenience, or economical considerations might lead to disobeying basic hygiene measures in anaesthesia. The most important recommendations are for: 1. General anaesthesia: bacterial filters prevent breathing circuit contamination from patient's expiratory secretions. This way reprocessing of reusable components is required only once a day or in case an external contamination has occurred; 2. Neuraxial blockade: use of sterile gloves, a surgical face mask, and a sterile gown is recommended; 3. Intravenous anaesthesia: equipment not manufactured for re-use may not be used for more than one patient under any circumstances. One-way-valves do not securely prevent retrograde contamination of the infusion system. Do not use multi dose vials unless declared by manufacturer. Alcoholic hand disinfection is the most important measure in order to avoid nosocomial pathogen transmission and infection.

Purpose: For the first time an evaluation of standard anesthetic monitoring was performed according to the guidelines of the Austrian Society for Anesthesiology, Resuscitation und Intensive Care Medicine (OGARI)., Methods: A questionnaire was delivered to all medical institutions performing anesthesia in Austria. A descriptive statistical evaluation was performed on all returned and completed questionnaires., Results: Generally, there is a high standard in compulsory monitoring and in PACU (actual compliance > 99%/85.8%). Supplemental equipment is required for disconnection alarm and measurement of inspired oxygen concentration (actual compliance: 98.3%/98.9%). Furthermore, measurement for inspired concentration of volatile anesthetics and relaxometry (actual compliance 68.7%/47.3%) has yet to be completed. University departments and regional hospitals have comparable standards (82.2% vs. 79.6%)., Conclusions: For the first time an Austrian-wide evaluation of anesthetic monitoring investigated the compliance with the 1992 recommendations of the Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine. The data demonstrate that these recommendations including the anesthetic monitoring equipment have already been implemented to a high degree.

Purpose: Since 1992 421,851 anaesthesias were documented by 39 institutes with a standard dataset issued by the German Society of Anaesthesiology and Intensive Care (DGAI). The project was run by the Association for Quality Assurance (EQS) in Hamburg. Some results of the evaluation of this datapool are presented questioning the feasibility of the project to support improvement processes within the participating institutions and which adjustments should be done considering these experiences., Methods: Data from machine-readable protocols and documentation software representing all anaesthesia cases were recorded since 1992 in a pilot project and since 1994 compulsory with a standard dataset issued by the DGAI. Comparing statistics of these data was produced at the EQS project office. In the steering committee and in meetings of the project participants the contents, policy and results of the project office. In the steering committee and in meetings of the project were critically analysed and adjustments initiated whenever necessary. Validity of data and feasibility of the method used was also questioned on the background of comparable studies., Results: With an incidence of 14.1% of all anaesthesias with special occurrences (AVB) the results are in the same range if compared with most other studies. However, documentation of data is not complete. This is assumed to be due to the large size of the dataset with 112 items and the additional workload associated with it. Nevertheless the participants mostly consider the project to be a very useful support for internal improvement projects., Conclusion: The project method used so far is not mature yet. The data set must be streamlined and rendered more concise, quality indicators should be defined and tested, and the availability of statistically proven limits of tolerance should be the immediate aims in the further development of the project.