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Purpose The semi-sitting position for resection of posterior fossa tumors is a matter of ongoing debate. Here we report about our experience with this approach in children younger than 4 years of age. Methods We retrospectively analyzed data of children younger than 4 years of age operated on in our institution in the semi-sitting position over a 15-year period. Patients were intraoperatively monitored for venous air embolism (VAE) by transthoracic Doppler (TTD) or transesophageal echocardiography (TEE). The severity of VAE was classified according to the Tübingen grading scale. Intraoperative incidents of VAE were recorded and the patients’ course was followed postoperatively with a special focus on possible complications. Results Twenty-four children (18 boys, 6 girls) were operated on in the semi-sitting position (26 operations). Mean age was 2.2 years (± 1.0), range between 0.4 and 3.9 years. External ventricular drains were inserted in 18 children with hydrocephalus preoperatively. VAE was detected in 6 instances during surgery (6/26 (23.1%)). In 3 patients with grade 1 VAE, no additional treatment was necessary. In one patient with grade 2 VAE, intracardiac air suction via the central venous catheter was performed, and in two patients with grade 4 VAE, additional cathecholamine-infusion was administered. No major intraoperative complications occurred. Postoperative CT images showed pneumocephalus in all children. In two children, small asymptomatic impression skull fractures at the site of the Mayfield pin occurred. Revision surgery was necessary in one child with a suboccipital CSF fistula. Conclusion The semi-sitting position for resection of tumors in the posterior fossa in children younger than 4 years of age can be safely performed in experienced centers taking special caution to detect and treat potential complications in an interdisciplinary setting.

Postoperative neurocritical intensive care unit (NICU) admission of patients who underwent craniotomy for close observation is common practice. In this study, we performed a comparative analysis to determine if there is a real need for NICU admission after microvascular decompression (MVD) for cranial nerve disorders or whether it may be abandoned. The present study evaluates a consecutive series of 236 MVD surgeries performed for treatment of trigeminal neuralgia (213), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2). All patients were operated by the senior surgeon according to a standard protocol over a period of 12 years. Patients were admitted routinely to NICU during the first phase of the study (phase I), while in the second phase (phase II), only patients with specific indications would go to NICU. While 105 patients (44%) were admitted to NICU postoperatively (phase I), 131 patients (56%) returned to the ward after a short stay in a postanaesthesia care unit (PACU) (phase II). Specific indications for NICU admission in phase I were pneumothorax secondary to central venous catheter insertion (4 patients), AV block during surgery, low blood oxygen levels after extubation, and postoperative dysphagia and dysphonia (1 patient, respectively). There were no significant differences in the distribution of ASA scores or the presence of cardiac and pulmonary comorbidities like congestive heart failure, arterial hypertension, or chronic obstructive pulmonary disease between groups. There were no secondary referrals from PACU to NICU. Our study shows that routine admission of patients after eventless MVD to NICU does not provide additional value. NICU admission can be restricted to patients with specific indications. When MVD surgery is performed in experienced hands according to a standard anaesthesia protocol, clinical observation on a neurosurgical ward is sufficient to monitor the postoperative course. Such a policy results in substantial savings of costs and human resources.

Liver transplantation is regarded as the gold standard for the treatment of a variety of fatal hepatic diseases. However, unsolved issues of chronic graft failure, ongoing organ donor shortages, and the increased use of marginal grafts call for the improvement of current concepts, such as the implementation of organ machine perfusion. In order to evaluate new methods of graft reconditioning and modulation, translational models are required. With respect to anatomical and physiological similarities to humans and recent progress in the field of xenotransplantation, pigs have become the main large animal species used in transplantation models. After the initial introduction of a porcine orthotopic liver transplant model by Garnier et al. in 1965, several modifications have been published over the past 60 years. Due to specifies-specific anatomical traits, a veno-venous bypass during the anhepatic phase is regarded as a necessity to reduce intestinal congestion and ischemia resulting in hemodynamic instability and perioperative mortality. However, the implementation of a bypass increases the technical and logistical complexity of the procedure. Furthermore, associated complications such as air embolism, hemorrhage, and the need for a simultaneous splenectomy have been reported previously. In this protocol, we describe a model of porcine orthotopic liver transplantation without the use of a veno-venous bypass. The engraftment of donor livers after static cold storage of 20 h - simulating extended criteria donor conditions - demonstrates that this simplified approach can be performed without significant hemodynamic alterations or intraoperative mortality and with regular uptake of liver function (as defined by bile production and liver-specific CYP1A2 metabolism). The success of this approach is ensured by an optimized surgical technique and a sophisticated anesthesiologic volume and vasopressor management. This model should be of special interest for workgroups focusing on the immediate postoperative course, ischemia-reperfusion injury, associated immunological mechanisms, and the reconditioning of extended criteria donor organs.

Zusammenfassung Hintergrund Die Punktion der V. subclavia gehört zu den Standardprozeduren eines/einer Anästhesisten/Anästhesistin. Gefürchtete Komplikationen dieser Prozedur sind der Pneumothorax und die arterielle Fehlpunktion. Zum Erlernen dieser Prozedur ist von einer gewissen Lernkurve auszugehen. Ziel der Arbeit In dieser Studie soll der Einfluss der Punktionserfahrung auf die Erfolgsquote und mechanische Komplikationen wie Pneumothorax und arterielle Punktion untersucht werden. Dazu sollen 3 Erfahrungsstufen miteinander verglichen werden: unerfahren: 0 bis 20 Punktionen, mäßig erfahren: 21 bis 50 und erfahren: über 50 Punktionen. Material und Methoden Post-hoc-Analyse einer vorab publizierten Nichtunterlegenheitsstudie zur Untersuchung des Einflusses der Beatmung auf die Pneumothoraxrate bei der V.-subclavia-Punktion in Landmarkentechnik. Es wurden 1021 Patienten ausgewertet, die in die vorab publizierte Studie zwischen August 2014 und Oktober 2017 eingeschlossen wurden. Ergebnisse Die Gesamtrate an mechanischen Komplikationen ist in der Gruppe der Unerfahrenen im Vergleich zur Gruppe der Erfahrenen signifikant höher (15 % vs. 8,5 %, p = 0,023). Ebenso ist die Rate an Punktionsversuchen in der Gruppe der Unerfahrenen (0–20) mit 1,85 ± 1,12 signifikant höher als in der Gruppe der Erfahrenen (1,58 ± 0,99, p = 0,004). Im Gegenzug war die Rate einer erfolgreichen Punktion mit 95,1 % in der Gruppe der Erfahrenen signifikant höher als in der Gruppe der Unerfahrenen (89,3 %, p = 0,001). Schlussfolgerung Für eine erfolgreiche Punktion der V. subclavia in Landmarkentechnik ist eine Lernkurve von mindestens 50 Punktionen nötig, um die Komplikationsrate zu senken und die Erfolgsrate zu steigern.

ZusammenfassungEine immer weiterentwickelte und erfolgreiche Transplantationsmedizin sorgt für eine große Zahl an lebenden transplantierten Patienten. Ein anästhesiologisch tätiger Arzt muss damit rechnen, mit einem solchen Patienten in Berührung zu kommen. Neben der präoperativen Beurteilung der Vorerkrankungen, inklusive der Funktion des transplantierten Organs, kommt auch der Immunsuppression eine bedeutende Rolle zu. Diese muss perioperativ immer sorgfältig fortgeführt werden. Ein striktes Einhalten aller hygienischen Vorschriften ist bei diesen Patienten aufgrund der Immunsuppression und des damit verbundenen erhöhten Infektionsrisikos essenziell. Dazu gehört auch die strenge Nutzen-Risiko-Bewertung aller invasiven Maßnahmen.Bei der Durchführung der Anästhesie und dem Einsatz der Anästhetika zeigen sich für diese Patienten keine wesentlichen Unterschiede zu nicht transplantierten Patienten, vielmehr muss hier das Augenmerk auf eine ausgeglichene Homöostase aller Organsysteme gerichtet werden.

BACKGROUND The indication of hydroxyethyl starch is currently under critical discussion and albumin 5% (ALB) has an increasing use in the operating theatre. Therefore, ALB is routinely used in neurosurgical procedures and often combined with mannitol 20% (MAN). Purpose of this in vitro study was to determine the influence of the combination of MAN and ALB on blood coagulation and platelet function. METHODS 22 healthy volunteers were included into this study and 21 analysed. Blood was obtained and diluted into five groups: (1) 7% dilution with MAN, (2) 10% dilution with ALB (3) 17% dilution with isotonic balanced electrolyte solution, (4) 17% dilution with MAN + ALB and (5) undiluted blood as control group (CON). Rotational thrombelastometry via ROTEM® (EXTEM, FIBTEM-Test) and thrombocyte aggregometry via Multiplate® (ASPI, ADP and TRAP-test) were used to detect differences within the intervention groups and compared to the control group. RESULTS The maximum clot firmness in the FIBTEM test decreased under the normal range with the combination of MAN+ALB: 8mm (5.5-11) compared to CON: 15mm (12.5-20), p

Introduction Laryngeal tubes (LT) are supraglottic airway devices routinely used in emergency airway management. During cardiac arrest in a swine model, the carotid artery blood flow is reduced after insertion of a LT. A compression of the internal carotid (ICA) artery by the inflated cuff was shown. Up to now there is no information if the LT has similar effects in humans with possible negative implications for use of the LT in case of cardiac arrest. Objective We hypothesized that the use of a LT in humans significantly reduces the blood flow in the ICA compared facemask ventilation. A significant reduction was defined as a 25% reduction from baseline values. Material and methods After induction of general anaesthesia and reaching a haemodynamic steady state (stable heart rate >50/min and mean arterial pressure >60 mmHg), blood flow within the ICA was measured via doppler sonography during pressure-controlled ventilation with facemask-, laryngeal tube- and laryngeal mask. Results We found no differences in the carotid blood flow. Neither between the facemask ventilation (right side 419 ± 159 ml min−1, left side 355 ± 120 ml min−1) and the laryngeal tube ventilation (right side 400 ± 131 ml min−1, left side 384 ± 124 ml min−1. p = 0.86 and p = 0.12), nor the facemask-ventilation and the laryngeal mask ventilation (right ICA 415 ± 150 ml min−1, left ICA 485 ± 274 ml min−1, p = 0.49 and 0.26). Conclusions In humans the LT does not impair blood flow of the internal carotid artery during ventilation in general anaesthesia. Further studies are needed to confirm our findings under the conditions of cardiac arrest.

OBJECTIVE Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period. METHODS The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed. RESULTS There were 404 women and 336 men with a mean age at surgery of 49 years (range 1–87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE. CONCLUSIONS This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.

Emergency medical services work in the environment of high responsibility teams and have to act under unpredictable working conditions. Stress occurs and has potential of negative effects on tasks, teamwork, prioritization processes and cognitive control. Stress is not exclusively dictated by the situation-the individuals rate the situation of having the necessary skills that a particular situation demands. There are different occupational groups in the emergency medical services in Germany. Training, tasks and legal framework of these groups vary.The aim of this study was to identify professional group-specific stressors for emergency medical services. These stress situations can be used to design skills building tools to enable individuals to cope with these stressors.The participants were invited to the study via posters and social media. An expert group (minimum 6 months of experience) developed a set of items via a two-step online Delphi survey. The experts were recruited from all professional groups represented in the German emergency medical service. We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we identified stress factors that could be grouped in relevant scales. In total 1017 participants (paramedics, physicians) took part in the final validation survey.After validation, we identified a catalogue of stressors with 7 scales and 25 items for EMT (Emergency Medical Technician) paramedics (KMO [Kayser-Meyer-Olkin criterion] 0.81), 6 scales and 24 items for advanced paramedics (KMO 0.82) and 6 scales and 24 items for EMS (Emergency Medical Service) physicians (KMO 0.82). For the professional group of EMT basic, the quality parameters did not allow further processing of the items. Professional group-specific scales for EMT paramedics are "professional limitations", "organizational framework", "expectations" and "questions of meaning". For advanced paramedics "appreciation", "exceptional circumstances" and "legal certainty" were identified. The EMT physicians named "handling third parties", "tolerance to ambiguity", "task management" and "pressure to act". A scale that is representative for all professional groups is "teamwork". Organizational circumstances occur in all groups. The item "unnecessary missions" for EMT paramedics and "legal concerns with the application of methods" for advanced paramedics are examples.Different stressors are relevant for the individual professional groups in the German emergency medical service. The developed catalogue can be used in the future to evaluate the subjective stress load of emergency service professionals. There are stressors that are inherent in the working environment (e.g. pressure to act) and others that can be improved through training (teamwork). We recommend training of general resistance as well as training of specific items (e.g., technical, nontechnical skills). All professionals mentioned items with respect to organizational factors. The responsible persons can identify potential for improvement based on the legal and organizational items. The EMT basic requires further subdivision according to task areas due to its variable applicability.HINTERGRUND: Rettungsdienste arbeiten unter den Bedingungen von „High Responsibility Teams“ und müssen auch unter unvorhersehbaren Arbeitsbedingungen agieren. Stress tritt auf und hat potenziell negative Auswirkungen auf Aufgaben, Teamarbeit und Priorisierungsprozesse.Das Ziel dieser Studie war es, berufsgruppenspezifische Stressoren für den Rettungsdienst zu identifizieren. Die identifizierten stressauslösenden Faktoren können genutzt werden, um Instrumente zum Aufbau von Fähigkeiten zu entwickeln, die es dem Einzelnen ermöglichen, mit diesen Stressoren umzugehen.Mittels einer zweistufigen Online-Delphi-Befragung, an der Teilnehmer aus allen im deutschen Rettungsdienst vertretenen Berufsgruppen teilnahmen, wurden Items entwickelt. Die daraus resultierenden Parameter wurden in einem größeren Kollektiv auf Relevanz und Validität überprüft. Schließlich wurden Belastungsfaktoren identifiziert, die in relevanten Skalen gruppiert werden konnten. Insgesamt nahmen 1017 Teilnehmer an der abschließenden Befragung teil.Nach der Validierung identifizierten wir einen Katalog von Stressoren mit 7 Skalen und 25 Items für Rettungsassistenten (KMO [Kayser-Meyer-Olkin Kriterium] 0,81), 6 Skalen und 24 Items für Notfallsanitäter (KMO 0,82) und 6 Skalen und 24 Items für Notärzte (KMO 0,82). Für die Berufsgruppe der Rettungssanitäter ließen die Gütekriterien keine weitere Bearbeitung der Items zu.Für die einzelnen Berufsgruppen im deutschen Rettungsdienst sind unterschiedliche Stressoren relevant. Der entwickelte Katalog kann in Zukunft zur Bewertung der subjektiven Stressbelastung von Rettungsdienstmitarbeitern eingesetzt werden. Der Rettungssanitäter bedarf aufgrund seiner unterschiedlichen Einsatzgebiete einer weiteren Untergliederung nach Aufgabenbereichen.

An ever-evolving and successful transplantation medicine is providing a large number of living patients after solid organ transplantation. Anaesthetists should therefore be prepared to come into contact with such a patient. In addition to the preoperative assessment of the pre-existing diseases, including the function of the transplanted organ, immunosuppression also plays an important role. Immunosuppression must always be continued perioperatively. Strict adherence to all hygienic regulations is essential in these patients due to immunosuppression and the associated increased risk of infection and sepsis. This includes the strict risk-benefit assessment of all invasive procedures.There are no significant differences between the anaesthetic approaches and agents in transplant and non-transplant patients. However, in the first group, homeostasis of all organ systems should be more focused on.

The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.HINTERGRUND: Die Punktion der V. subclavia gehört zu den Standardprozeduren eines/einer Anästhesisten/Anästhesistin. Gefürchtete Komplikationen dieser Prozedur sind der Pneumothorax und die arterielle Fehlpunktion. Zum Erlernen dieser Prozedur ist von einer gewissen Lernkurve auszugehen.In dieser Studie soll der Einfluss der Punktionserfahrung auf die Erfolgsquote und mechanische Komplikationen wie Pneumothorax und arterielle Punktion untersucht werden. Dazu sollen 3 Erfahrungsstufen miteinander verglichen werden: unerfahren: 0 bis 20 Punktionen, mäßig erfahren: 21 bis 50 und erfahren: über 50 Punktionen.Post-hoc-Analyse einer vorab publizierten Nichtunterlegenheitsstudie zur Untersuchung des Einflusses der Beatmung auf die Pneumothoraxrate bei der V.-subclavia-Punktion in Landmarkentechnik. Es wurden 1021 Patienten ausgewertet, die in die vorab publizierte Studie zwischen August 2014 und Oktober 2017 eingeschlossen wurden.Die Gesamtrate an mechanischen Komplikationen ist in der Gruppe der Unerfahrenen im Vergleich zur Gruppe der Erfahrenen signifikant höher (15 % vs. 8,5 %, p = 0,023). Ebenso ist die Rate an Punktionsversuchen in der Gruppe der Unerfahrenen (0–20) mit 1,85 ± 1,12 signifikant höher als in der Gruppe der Erfahrenen (1,58 ± 0,99, p = 0,004). Im Gegenzug war die Rate einer erfolgreichen Punktion mit 95,1 % in der Gruppe der Erfahrenen signifikant höher als in der Gruppe der Unerfahrenen (89,3 %, p = 0,001).Für eine erfolgreiche Punktion der V. subclavia in Landmarkentechnik ist eine Lernkurve von mindestens 50 Punktionen nötig, um die Komplikationsrate zu senken und die Erfolgsrate zu steigern.

Objective Mannitol 20% and succinylated gelatin 4% are routinely used in neurosurgical procedures. The aim of this in vitro study was to explore the influence of both agents on blood coagulation and platelet function. Methods Blood from 21 healthy volunteers was obtained and then diluted so as to form five groups: (1) 7% dilution with mannitol; (2) 10% dilution with gelatin; (3) 17% dilution with isotonic balanced electrolyte solution; (4) 17% dilution with mannitol+gelatin; and (5) undiluted blood. The extrinsic thrombelastometry (EXTEM) and fibrin thrombelastometry (FIBTEM) tests were examined by rotational thrombelastometry via ROTEM®, and thrombocyte aggregometry with the aspirin inhibiting- (ASPI), adenosine diphosphate- (ADP), and thrombin-activating protein (TRAP) tests performed by Multiplate. Results In the EXTEM test clot formation time, the alpha angle, and maximum clot firmness were significantly reduced by mannitol and the combination of mannitol with gelatin. The platelet function tested in the ADP test was also significantly reduced with this combination. Conclusion In this in vitro study, clinically relevant dilutions of mannitol and gelatin showed a significant inhibition of whole blood coagulation and the platelet function, which could be detrimental in neurosurgical settings.

Jahrlich werden tausende Patienten in sitzender Position operiert. Meist handelt es sich um die Beach-Chair-Lagerung (BCL). Durch Fallberichte uber deletare neurologische Verlaufe nach Operationen in BCL und Allgemeinanasthesie wird die Sicherheit der BCL unter Allgemeinanasthesie kontrovers diskutiert. Diese Ubersichtsarbeit stellt die lagerungsbedingten Komplikationsmoglichkeiten dar und gibt Hilfestellung fur die tagliche Praxis.

Erratum zu: Anaesthesist 2019 https://doi.org/10.1007/s00101-019-0579-x In dem ursprunglichen Artikel wurde der Name des Autors Lion Sieg falsch geschrieben. Der Originalbeitrag wurde korrigiert.

There is an ongoing debate about the sitting position (SP) in neurosurgical patients. The SP provides a number of advantages as well as severe complications such as commonly concerning venous air embolism (VAE). The best monitoring system for the detection of VAE is still controversial. In this retrospective analysis we compared 208 patients. Transesophageal echocardiography (TEE) or transthoracic Doppler (TTD) were used as monitoring devices to detect VAE; 101 cases were monitored with TEE and 107 with TTD. The overall incidence of VAE was 23% (TTD: 10%; TEE: 37%), but the incidence of clinically relevant VAE (drop in end-tidal carbon dioxide above 3 mmHg) was higher in the TTD group (9 out of 17 VAE, 53%) compared to the TEE group (19 out of 62 VAE, 31%). None of the patients with recorded VAE had clinically significant sequelae. In this small sample we found more VAE events in the TEE group, but the incidence of clinically relevant VAE was rare and comparable to other data. There is no consensus in the definition of clinically relevant VAE.

In Deutschland leben derzeit mehr als 17000 Menschen, die ein Organ transplantiert bekommen haben. Fur den anasthesiologisch tatigen Arzt impliziert dies, dass er im Laufe seiner arztlichen Tatigkeit damit rechnen muss, mit einem solchen Patienten in Beruhrung zu kommen. Dabei kommt neben der praoperativen Beurteilung, inklusive der Funktion des transplantierten Organs, auch der Immunsuppression eine bedeutende Rolle zu. Hier muss in enger Zusammenarbeit mit dem Patienten und der fur ihn zustandigen Transplantationsambulanz die Fortfuhrung der perioperativen Immunsuppression sorgfaltig geplant werden. Ein streng hygienisches Vorgehen ist bei diesen Patienten aufgrund der Immunsuppression und dem damit verbundenen erhohten Infektionsrisiko essenziell. Dazu gehort auch die strenge Nutzen-Risiko-Bewertung aller invasiven Masnahmen. Bei der Durchfuhrung der Anasthesie und dem Einsatz der Anasthetika zeigen sich fur diese Patienten keine wesentlichen Unterschiede zu nicht transplantierten Patienten. Vielmehr muss hier das Augenmerk auf eine ausgeglichene Homoostase aller Organsysteme gerichtet werden.

Every year thousands of patients are operated in the sitting position. The most common position is the beach chair position. Due to case reports with deleterious neurologic outcome, the safety of the beach chair position in combination with general anesthesia is discussed controversially. In this review article the possible complications according to the beach chair position are explained and practical advice is given for the daily anesthetic routine.

More than 17000 patients currently live in Germany who have had organ transplants. The implications of this for the anaesthetists are that they are very likely to be confronted by such a patient at some point during their active career. Besides the preoperative assessment which includes that of the function of the transplanted organ, appropriate immunosuppression poses a particular challenge. Close collaboration with both patients and their transplant specialists is essential to preempt the perioperative consequences and plan continuation of immunosuppression. Strictly aseptic measures are mandatory as well as detailed evaluation of the risk-benefit balance of all invasive procedures.There are no significant differences between the anaesthetic approaches and agents in transplant and non-transplant patients. However, in the latter group, homeostasis of all organ systems should be more focused on.

Background Milrinone used for acute cardiac insufficiency could be of interest during cardiopulmonary resuscitation because of its positive inotropic effects. In this study, the combination of milrinone-vasopressin was compared with epinephrine and vasopressin, as well as with the combination of epinephrine-vasopressin, in reference to hemodynamics. Methods Thirty-two pigs underwent ligation of the circumflex coronary artery and induction of ventricular fibrillation lasting for 4 min. Cardiopulmonary resuscitation was performed after randomization to one of four groups: epinephrine (30-microg/kg bolus), vasopressin (0.4-U/kg bolus), epinephrine-vasopressin (15-microg/kg epinephrine bolus, 0.2-U/kg vasopressin bolus), or milrinone-vasopressin (0.4-U/kg vasopressin bolus, 50-microg/kg milrinone bolus over 5 min and a continuous infusion of 0.4 microg.kg.min). The hemodynamic variables were measured before cardiopulmonary resuscitation as well as 4, 8, 15, and 30 min after return of spontaneous circulation. Results All animals were resuscitated successfully. The animals of the milrinone-vasopressin group displayed significantly (P Conclusions The combination of vasopressin-milrinone as compared with epinephrine during cardiopulmonary resuscitation leads to an improved cardiac index without relevant decrease of mean arterial pressure or coronary perfusion pressure.

Background: Aortic arch operations in pediatric patients using low-flow perfusion techniques have been standardized to a certain degree, but some of the often-stated beneficial effects have never been proven. Especially, the existence or efficacy of any subdiaphragmal perfusion still remains unclear.Methods:Twenty-six newborn male piglets (10—15 kg) underwent aortic arch surgery under general anesthesia using either lowflow perfusion via the innominate artery (LF, 30 ml/(kg min), 25 8C, n = 12) or conventional deep hypothermic circulatory arrest (DHCA, 20 8C, n = 14). Cortical somatosensory-evoked potentials (SSEPs), carotid, and subdiaphragmal blood flows were measured. The animals of both groups have been randomized to either pH-stat or alpha-stat management on cardiopulmonary bypass (CPB). Results: During low-flow perfusion via the innominate artery only negligible flows of maximum 1—3 ml/min in the femoral arteries were detected, whereas the right carotid artery flow doubled. During reperfusion, serum-lactate and aspartate amino-transferase (AST) levels were significantly higher compared to the circulatory arrest group, whereas alanine amino-transferase (ALT), gamma-glutamyl transpeptidase (gamma-GT), AP, and creatinine did not show any significant differences. Cortical SSEP returned to preoperative values in all but two low-flow animals. There was no return of SSEP in all piglets operated under deep hypothermic circulatory arrest (p < 0.01). Conclusion: Compared to DHCA, low-flow perfusion via the innominate artery provides superior neuroprotection despite higher tissue temperatures. Although collateral blood flow via the subclavian artery and the circulus arteriosus willisii has often been presumed, only ‘trickle-flow’ with some protective potential was detectable in the femoral arteries during lowflow perfusion. Origin of elevated lactate and AST levels seems to be the lower limbs.

To determine perioperative changes in circulating (BVI) and central blood volume (CBVI) by a new dye dilution technique using pulse dye densitometry. Prospective observational study in the cardiac anesthesia and intensive care unit of a university hospital. Sixty-six patients undergoing coronary artery bypass surgery. Hemodynamic measurements by the dye dilution method using pulse dye densitometry were performed prior to skin incision and 3.3±1.4 h and 17±2.7 h after surgery. Based on conventional monitoring the therapeutic goals of hemodynamic therapy were achieved in all of the patients of this study. Despite a marked positive fluid balance which developed during surgery mean BVI decreased significantly after surgery while CBVI remained unchanged. Postoperative BVI deficits vs. preoperative values were observed in 78% of patients; these BVI deficits were profound in 29% of the cases. In contrast, 65% of the individual patients showed no or only minor postoperative changes in CBVI vs. preoperative values. Changes in the intravascular volume compartments affected BVI to a greater extent than CBVI. Therefore measuring circulating in addition to central blood volume may be useful to ensure a normal circulating blood volume that can compensate for any change in the central vascular compartment.

The relation of procalcitonin (PCT) plasma concentrations comparedwith C-reactive protein (CRP) was analyzed in patients with different severityof multiple organ dysfunction syndrome (MODS) and systemic inflammation. PCT, CRP, the sepsis-related organ failure assessment (SOFA)score, the Acute Physiology, Age, Chronic Health Evaluation (APACHE) II scoreand survival were evaluated in 40 patients with systemic inflammation andconsecutive MODS over a period of 15 days. Higher SOFA score levels were associated with significantly higherPCT plasma concentrations (SOFA 7-12: PCT 2.62 ng/ml, SOFA 19-24: PCT15.22 ng/ml) (median), whereas CRP was elevated irrespective of the scoresobserved (SOFT 7-12: CRP 131 mg/l, SOFT 19-24: CRP 135 mg/l). PCT ofnon-surviving patients was initially not different from that of survivors butsignificantly increased after the fourth day following onset of the disease,whereas CRP was not different between both groups throughout the wholeobservation period. Measurement of PCT concentrations during multiple organdysfunction syndrome provides more information about the severity and thecourse of the disease than that of CRP. Regarding the strong association of PCTand the respective score systems in future studies we recommend evaluation alsoof the severity of inflammation and MODS when PCT concentrations were comparedbetween different types of disease.