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Non-invasive haemoglobin measurement using absolute values lacks the precision to be the sole basis for the treatment of pre-operative anaemia. However, it can possibly serve as a screening test, indexing 'anaemia' with high sensitivity when values remain under prespecified cut-off values. Based on previous data, non-invasive haemoglobin cut-off values (146 g.l-1 for women and 152 g.l-1 for men) detect true anaemia with 99% sensitivity. An index test with these prespecified cut-off values was verified by prospective measurement of non-invasive and invasive haemoglobin pre-operatively in elective surgical patients. In 809 patients, this showed an estimated sensitivity (95%CI) of 98.9% (94.1-99.9%) in women and 96.4% (91.0-99.0%) in men. This saved invasive blood tests in 9% of female and 28% of male patients. In female patients, a lower non-invasive haemoglobin cut-off value (138 g.l-1 ) would save 28% of invasive blood tests with a sensitivity of 95%. The target 99% sensitivity would be reached by non-invasive haemoglobin cut-off values of 152 g.l-1 in female and 162 g.l-1 in male patients, saving 3% and 9% of invasive blood tests, respectively. Bias and limits of agreement between non-invasive and laboratory haemoglobin levels were 2 and - 25 to 28 g.l-1 , respectively. Patient and measurement characteristics did not influence the agreement between non-invasive and laboratory haemoglobin levels. Although sensitivity was very high, the index test using prespecified cut-off values just failed to reach the target sensitivity to detect true anaemia. Nevertheless, with respect to blood-sparing effects, the use of the index test in men may be clinically useful, while an index test with a lower cut-off (132 g.l-1 ) could be more clinically appropriate in women.

Zusammenfassung Einleitung In der Neonatologie kann es für verschiedene Fragestellungen von Bedeutung sein, den Anteil des fetalen Hämoglobins (HbF) am Gesamt-Hämoglobin zu kennen. Blutgasanalysegeräte (BGA-Geräte) bieten die Bestimmung des Anteils des HbF an, es ist jedoch nicht bekannt, wie valide diese Messungen sind. In dieser Studie wurde die Genauigkeit der Bestimmung des HbF durch das BGA-Gerät der Fa. Radiometer untersucht. Material und Methode Bei früh- und reifgeborenen Neugeborenen wurde der Anteil des HbF sowohl durch das BGA-Gerät (HbFgas) als auch den Labor-Goldstandard (HbFlab) bestimmt. Die Übereinstimmung wurde mithilfe der Bland Altman-Methode und der Berechnung der Wurzel aus dem quadratischen Fehler (RMSE) untersucht. Ergebnisse Bei 23 früh- und reifgeborenen Neugeborenen (medianes Körpergewicht 2190g, Minimum–Maximum 967–3800 g, medianes postmenstruelles Alter 36+1 Wochen, Minimum–Maximum 29+6–43+2 Wochen) wurden 35 Messungen des HbF mit beiden Methoden durchgeführt. Der Mittelwert der Differenzen (bias, HbFgas-HbFlab) betrug 9,3%, der Übereinstimmungsbereich bewegte sich zwischen 1 bis 17,6%. Der RMSE war 10,2%. 45,7% der HbFgas-Messungen wichen mehr als 10% vom Goldstandard ab. Es zeigte sich kein relevanter Einfluss von Lebensalter, Körpertemperatur und Sauerstoffsättigung auf den bias (p= 0,132; p= 0,194; p= 0,970). Der bias nimmt mit höherem HbFlab tendenziell zu (Pearson-Korrelation r=0,426; p= 0,011). Schlussfolgerung Die Messung des HbF in früh-und reifgeborenen Neugeborenen mittels BGA-Gerät überschätzte den Anteil des HbF am Gesamt-Hämoglobin. Die Übereinstimmung mit dem Goldstandard war unzureichend. Der Einsatz eines BGA-Gerätes zur Messung des HbF-Anteils kann für die klinische und wissenschaftliche Entscheidungsfindung in diesem Patientenkollektiv daher nicht empfohlen werden.

Purpose of review Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients. Recent findings This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations. Summary Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.

IntroductionPostoperative sore throat (POST) is a comparatively minor but very common side effect of general anaesthesia with a supraglottic airway device. The patient considers these side effects a mirror of the quality of anaesthesia. The aims of this study are to evaluate gender-specific differences in the incidence of POST and to assess whether the effects of known risk factors vary between genders.Methods and analysisThe LadyLAMA trial is a single-centre, patient-blinded, randomised controlled trial. Consecutive patients requiring ophthalmological surgery under general anaesthesia with a second generation Ambu AuraGain laryngeal mask are randomly allocated to either cuff pressure of 45 cmH2O or cuff pressure of 60 cmH2O. We estimate the difference in POST between the genders at 20% and we hypothesised that a reduction of cuff pressure would reduce POST by 10%. A total of 800 patients will be recruited, with each subgroup including 200 patients to achieve 80% power for detecting a difference at the 5% significance level. Primary endpoints are gender differences in the incidence of POST within 24 hours postoperatively, as well as comparison of cuff pressure 45 cmH2O to 60 cmH2O with respect to POST. The main secondary objective is the effect of cuff pressure on POST stratified by gender. Further secondary endpoints are gender-specific differences in POST and hoarseness in postanaesthesia care unit (PACU) at 48 and 72 hours (or until freedom of discomfort). The parameter cuff pressure serves as key-secondary endpoint.Ethics and disseminationThe project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (Nr. 2021-15835). The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings.Trial registration numberNCT04915534.

There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners.To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps.A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices.A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques.Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.HINTERGRUND: Es besteht ein weltweiter Konsens unter Experten, dass Leitlinien und Algorithmen zum Atemwegsmanagement zu einer verbesserten Patientensicherheit in der Anästhesie beitragen. Diese Studie beschreibt die aktuelle Praxis des Atemwegsmanagements deutscher Anästhesisten und identifiziert Sicherheitslücken, definiert als Differenz zwischen der durch den Antwortenden berichteten Praxis und Empfehlung.Ermittlung der Umsetzung der Leitlinie zum Atemwegsmanagement in der Praxis durch deutsche Anästhesisten und Identifizierung möglicher Safety Gaps.Im September 2019 wurde eine Online-Umfrage durchgeführt. Alle registrierten Mitglieder der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) wurden per E‑Mail kontaktiert. Die Teilnehmer wurden nach ihrem persönlichen und institutionellen Hintergrund, der Einhaltung der Empfehlungen der aktuellen deutschen S1-Leitlinie und der Verfügbarkeit von Gerätschaften zur Atemwegssicherung befragt.Insgesamt 1862 DGAI-Mitglieder füllten die Fragebögen vollständig aus (Rücklaufquote: 17 %). Das Hauptergebnis war, dass sich die Anästhesisten größtenteils an die Leitlinie hielten, jedoch zeigten bestimmte Empfehlungen, insbesondere in Bezug auf die Besonderheiten der Präoxygenierung und der Ausbildung, eine Sicherheitslücke. Mehr als 90 % der Teilnehmer verfügten über ein Videolaryngoskop und die Hälfte hatte mehr als 25 Intubationen im Wachzustand mit einer flexiblen Optik durchgeführt. Allerdings verfügten nur 81 % über ein Videolaryngoskop mit stärker gekrümmtem Spatel. Schätzungsweise 16 % aller Intubationen erfolgten mit einem Videolaryngoskop, und jeder vierte Teilnehmer hatte damit eine Intubation im Wachzustand durchgeführt. Fast alle Teilnehmer hatten Patienten mit erwartet schwierigen Atemwegen betreut. Die Hälfte der Teilnehmer war bereits mit einer CICO-Situation konfrontiert und jeder fünfte musste mindestens einmal eine Notfallkoniotomie durchführen. In diesem Fall verwendeten fast zwei Drittel Punktionstechniken und ein Drittel ein Skalpell.Die derzeitige Praxis des Atemwegsmanagements zeigte insgesamt eine gute Übereinstimmung mit den Empfehlungen der aktuellen deutschen Leitlinie zum Atemwegsmanagement, dennoch besteht insbesondere bei der Ausbildung Verbesserungsbedarf.

Introduction Esophageal atresia (EA) is a rare malformation that often requires a series of procedures, including surgical primary anastomosis, staged repair, and endoscopic procedures. Actual numbers and trends in interventions and variety in treatment strategies remain unclear. Materials and Methods Data from the German federal bureau of statistics containing all EA-related inpatient procedures encoded from 2005 until 2018 were analyzed for children during the first year of life. The sum of esophageal anastomoses and replacements was used to calculate an estimate of incidence of EA. Results Over 14 years, 12,627,888 inpatient cases were recorded in infants in Germany. The mean incidence of EA was 1 per 4,217 live births. On average, 163.3 (95% confidence interval [CI]: 150.8–176.1) esophageal anastomoses, 11.2 (95% CI: 8.7–13.7) esophageal lengthening procedures, and 6.7 (95% CI: 5.42–8.00) esophageal replacements were recorded annually. Overall, 187.8 (95% CI: 147.1–200.4) endoluminal treatments (ballon dilatation, bougienage, stent placement, or injection) were performed per 100 anastomoses. Over the years, bougienage was increasingly replaced by ballon dilatation as primary treatment. Boys had a significantly higher number of esophageal procedures than girls, but the incidence of endoscopic treatments in relation to anastomoses was the same for both genders. Conclusion The low incidence of EA in relation to a relatively large number of units treating those patients in Germany may pose challenges for maintaining competency and training of all specialists involved. The number of esophagoscopic treatments for esophageal stricture per anastomosis is lower than previously estimated.

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5–10] s, the median TTP was 28 [19–44] s, and the median TTV was 51 [39–66] s. DL-mediated intubation was significantly faster (TTP: 17 [13–23] s; p < 0.0001 and TTV: 34 [28–44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

In neonatologic clinical practice and research the percentage of fetal hemoglobin (HbF) of total hemoglobin can be of interest. Blood gas analyzers offer the measurement of HbF. However, it is not known if results are accurate enough to apply in clinical decision-making or scientific questions. In this prospective diagnostic study, we examined the accuracy of HbF measurement by a blood gas analyzer.On a neonatal intensive care and neonatal ward, the percentage of HbF was measured using both the laboratory gold standard (HbFlab, reference method) and the blood gas analyzer (HbFgas) (ABL 800 Flex, Radiometer). Agreement of HbFlab and HbFgas was assessed by the Bland-Altman method including bias and limits of agreement and by calculation of the root mean square error (RMSE).Thirty-five measurements in 23 term and preterm infants with a median body weight of 2190 g (min-max 967-3800 g) and a median postmenstrual age of 36+1 weeks (min-max 29+6-43+2) were performed. The Bland-Altman diagram for the measurement of HbF(gas) versus HbF(lab) shows an overestimation of HbF by the blood gas analyzer (bias 9.3%, limits of agreement 1 to 17.6%). RMSE was 10.2%; 45.7% of HbFgas measurements were10% out of range from HbFlab. There was no influence of age, body temperature or oxygen saturation on the bias (p=0,132; p=0,194; p=0,970), but bias increased with increasing HbFlab (Pearson correlation r=0,426; p=0,011).The measurement of HbF in term and preterm infants by a blood gas analyzer lacked sufficient agreement with that of the reference method to recommend this application for clinical decision-making or scientific purposes.In der Neonatologie kann es für verschiedene Fragestellungen von Bedeutung sein, den Anteil des fetalen Hämoglobins (HbF) am Gesamt-Hämoglobin zu kennen. Blutgasanalysegeräte (BGA-Geräte) bieten die Bestimmung des Anteils des HbF an, es ist jedoch nicht bekannt, wie valide diese Messungen sind. In dieser Studie wurde die Genauigkeit der Bestimmung des HbF durch das BGA-Gerät der Fa. Radiometer untersucht.Bei früh- und reifgeborenen Neugeborenen wurde der Anteil des HbF sowohl durch das BGA-Gerät (HbFgas) als auch den Labor-Goldstandard (HbFlab) bestimmt. Die Übereinstimmung wurde mithilfe der Bland Altman-Methode und der Berechnung der Wurzel aus dem quadratischen Fehler (RMSE) untersucht.Bei 23 früh- und reifgeborenen Neugeborenen (medianes Körpergewicht 2190g, Minimum–Maximum 967–3800 g, medianes postmenstruelles Alter 36+1 Wochen, Minimum–Maximum 29+6–43+2 Wochen) wurden 35 Messungen des HbF mit beiden Methoden durchgeführt. Der Mittelwert der Differenzen (bias, HbFgas-HbFlab) betrug 9,3%, der Übereinstimmungsbereich bewegte sich zwischen 1 bis 17,6%. Der RMSE war 10,2%. 45,7% der HbFgas-Messungen wichen mehr als 10% vom Goldstandard ab. Es zeigte sich kein relevanter Einfluss von Lebensalter, Körpertemperatur und Sauerstoffsättigung auf den bias (p= 0,132; p= 0,194; p= 0,970). Der bias nimmt mit höherem HbFlab tendenziell zu (Pearson-Korrelation r=0,426; p= 0,011).Die Messung des HbF in früh-und reifgeborenen Neugeborenen mittels BGA-Gerät überschätzte den Anteil des HbF am Gesamt-Hämoglobin. Die Übereinstimmung mit dem Goldstandard war unzureichend. Der Einsatz eines BGA-Gerätes zur Messung des HbF-Anteils kann für die klinische und wissenschaftliche Entscheidungsfindung in diesem Patientenkollektiv daher nicht empfohlen werden.

A laboratory haematology analyser is the gold standard for measuring haemoglobin concentration but has disadvantages, especially in neonates. This study compared alternative blood-sparing and non-invasive methods of haemoglobin concentration measurement with the gold standard. Haemoglobin concentrations were measured using a laboratory haematology analyser (reference method), blood gas analyser, HemoCue® using venous and capillary blood samples and a newly developed non-invasive sensor for neonates < 3 kg. A total of 63 measurements were performed. Body weight (2190 (1820-2520 [967-4450]) g) and haemoglobin concentration (12.3 (10.6-15.2 [8.2-20.5]) g.dl-1 ) varied widely. Bias/limits of agreement between the alternative methods and reference method were -0.1/-1.2 to 1.0 g.dl-1 (blood gas analyser), -0.4/-1.8 to 1.1 g.dl-1 (HemoCue, venous blood), 0.7/-1.9 to 3.2 g.dl-1 (HemoCue, capillary blood) and -1.2/-4.3 to 2 g.dl-1 (non-invasive haemoglobin measurement). Perfusion index, body weight and fetal haemoglobin concentration did not affect the accuracy of the alternative measurement methods, and these were successfully applied in term and preterm infants. However, the accuracies of non-invasive haemoglobin measurement and HemoCue of capillary blood especially lacked sufficient agreement with that of the reference method to recommend these methods for clinical decision making.

Patient Blood Management beschreibt ein interdisziplinares Konzept, welches den adaquaten und rationalen Einsatz von Fremdblut unter Ausschopfen von validierten Strategien zur Pravention, Diagnostik und Therapie von Anamien, die Reduktion von Blutverlusten und Alternativen zur Fremdblutgabe zum Ziel hat. Wahrend Patient Blood Management in der Erwachsenenmedizin schon verbreitet ist, sind Konzepte fur die Behandlung von Kindern noch rar. Die Grundsatze der praoperativen Evaluation mit Optimierung des Erythrozytenvolumens, der perioperativen Minimierung von Blutverlusten, sowie des differenzierten Einsatzes von Blutprodukten gelten bei Erwachsenen wie bei Kindern. Wesentliche Unterschiede bestehen hinsichtlich der Physiologie des Hamoglobin- und des kardiovaskularen Systems vor allem bei Kindern im ersten Lebensjahr. Die zuverlassige Detektion einer drohenden anamischen Hypoxie kann bei Kindern erschwert sein, standardisierte Hamoglobin-Schwellenwerte als Indikation zur Transfusion sollten immer durch eine zusatzliche an den klinischen Befunden orientierte individuelle Risiko-Nutzen-Analyse gestutzt werden.

Background In infants, securing the airway is time-critical because of anatomical and physiological differences related to airway management in children less than 1 year old. The aim of this study was to compare the time to ventilation using two different hyperangulated video laryngoscope blades with the time to ventilation via conventional direct laryngoscopy in a normal airway [NA] and in a simulated difficult airway [DA]. Methods This study was a comparative, bicentric, open-label, randomized controlled evaluation. An infant high-fidelity simulator (SimBaby™; Laerdal® Medical, Stavanger, Norway) was used, and two scenarios were proposed, as follows: NA and DA evoked with tongue edema and cervical collar. After theoretical and practical briefing, each participant compared in the two airway scenarios the novel King Vision™ Pediatric aBlade (KV) (Ambu® A/S, Bad Nauheim, Germany) video laryngoscope and the C-MAC™ D-blade Ped (DB) (Karl Storz® SE & Co. KG, Tuttlingen, Germany) video laryngoscope to conventional laryngoscopy using the Miller Blade (MiB) and the Macintosh Blade (MaB) in a random sequence. Results Eighty physicians (65 AN and 15 PCCM staff) were included. In the NA scenario, the median [IQR] time to successful time to ventilation (TTV) was significantly shorter for the KV at 13 s [12–15 s] than for the MaB at 14.5 s [13–16 s], DB at 14.5 s [13–16] and MiB at 16 s [14–19] (p

Introduction 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. Methods In 60 healthy preoperative children (0.2-7.6 years old), hemoglobin was measured using a noninvasive method (SpHb; Radical-7 Pulse Co-Oximeter), a blood gas analyzer (clinical standard, BGAHb; ABL 800 Flex), and a laboratory hematology analyzer (reference method, labHb; Siemens Advia). Agreement between the results was assessed by Bland-Altman analysis and by determining the percentage of outliers. Results Sixty SpHb measurements, 60 labHb measurements, and 59 BGAHb measurements were evaluated. In 38% of the children, the location of the SpHb sensor had to be changed more than twice for the signal quality to be sufficient. The bias/limits of agreement between SpHb and labHb were -0.65/-3.4 to 2.1 g·dl(-1) . Forty-four percent of the SpHb values differed from the reference value by more than 1 g·dl(-1) . Age, difficulty of measurement, and the perfusion index (PI) had no influence on the accuracy of SpHb. The bias/limits of agreement between BGAHb and labHb were 1.14/-1.6 to 3.9 g·dl(-1) . Furthermore, 66% of the BGAHb values differed from the reference values by more than 1 g·dl(-1) . The absolute mean difference between SpHb and labHb (1.1 g·dl(-1) ) was smaller than the absolute mean difference between BGAHb and labHb (1.5 g·dl(-1) /P = 0.024). Conclusion Noninvasive measurement of hemoglobin agrees more with the reference method than the measurement of hemoglobin using a blood gas analyzer. However, both methods can show clinically relevant differences from the reference method (ClinicalTrials.gov: NCT01693016).

BACKGROUND Little is known about the current practice of the perioperative transfusion of red blood cells (RBCs) in pediatric patients. This study was performed to evaluate the practice of RBC transfusion in German pediatric anesthesia. STUDY DESIGN AND METHODS An online survey was conducted among members of the German Society of Anesthesiology and Intensive Care. Participants were asked to indicate the hemoglobin (Hb) thresholds for starting RBC transfusion in six cases of different bleeding situations in pediatric anesthesia. Demographics of participants, general knowledge, and application of transfusion rules and guidelines were assessed. RESULTS We included 1207 of 1396 returned questionnaires. Of the respondents, 89% were qualified specialists and 68% had experience in anesthesia in children aged less than 6 months. The lowest median Hb transfusion threshold was 6 g/dL in a 16-year-old and the highest was 10 g/dL in a premature neonate. Intraoperative Hb thresholds increased for clinically unstable (median difference to clinically stable children, +1 g/dL; p

Patient blood management describes an interdisciplinary concept which aims at rational and adequate use of blood products accompanied by strategies to prevent and treat anemia, to reduce blood loss and to use alternatives to blood transfusion. While patient blood management has been widely implemented in adult medicine, concepts for such measures in the care of children are rare. The basic principles of preoperative evaluation, optimization of blood volume, perioperative minimizing of blood loss and a differentiated use of blood products are effective both in adults and children. There are differences in the physiology of hemoglobin and cardiovascular systems, particularly in the first year of life. It can be difficult to determine impending anemic hypoxia in children, so that indication for transfusion based on standardized hemoglobin threshold values should always be supported by an individual risk-benefit analysis based on clinical assessment.

Ambulatory surgical care is intended to save healthcare expenditure from the economical viewpoint. From the patients point of view significant advantages as well as specific disadvantages of ambulatory surgery are known. The increase in the volume and complexity of procedures provided in an ambulatory setting are driven by improvements in anesthesia and surgical technique as well as by changes in financing and reimbursement. Therefore careful quality control and scientific evidence for the safety of increasingly used complex surgical procedures for higher risk patients is essential. Reducing the surgical trauma by minimally invasive surgical techniques and very good controllability by modern anesthesia concepts is making the management of the postoperative period crucial for successful ambulatory surgery. Most of the complications and common problems during the postoperative period, such as pain, nausea and vomiting, are not specific for ambulatory surgery, but management places an increasing burden of responsibility not only on general and specialised physicians, but also on other health professionals, patients, and family members.