[Hot topics in obstetric anesthesia]. / "Hot topics" aus der geburtshilflichen Anästhesie.

In 2019 the annual conference of the scientific working group on obstetric anesthesiology of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) took place in the usual manner. Emergency situations, such as the challenge of a preclinical birth or the recognition and treatment of an amniotic fluid embolism were discussed. In addition, topics on the correct treatment of a female patient with a known addictive disorder were of great interest as well as the discussion on the question when a transfusion should be performed in postpartum anemia and which risks accompany the increasing prevalence of obesity, especially during pregnancy. A further hot topic was the deliberation on the prevalence and differential diagnostic clarification of neurological complications after epidural anesthesia. In connection with the topic of birth, exciting and practice relevant topics for all anesthetists confronted with this field were presented and discussed. The essential aspects are summarized in this article.

[Septic shock in a female patient with miliary tuberculosis]. / Landouzy-Sepsis bei einer Patientin mit Miliartuberkulose.

This article reports the fulminant course of a pneumogenic sepsis with severe ARDS (acute respiratory failure) in a 36-year-old female Indian patient, who died within 14 h after admission to the intensive care unit due to a multiorgan failure. During treatment the diagnosis of a miliary tuberculosis was suspected but was only confirmed by the autopsy. Due to high hygiene standards, miliary tuberculosis as the cause of septic shock is rare in Europe. Only 1-2% of the patients with pulmonary miliary tuberculosis develop an ARDS with a mortality of 60-90%. Based on this case the diagnostics as well as treatment of the patient are described. Furthermore, the management of an open tuberculosis on an intensive care unit is explained.

["Why mothers die". Learning from the analysis of anaesthesia-related maternal deaths (1985-2013)]. / "Why mothers die". Was wir von der Analyse anästhesiebedingter mütterlicher Sterbefälle (1985-2013) gelernt haben.

Every day, more than 800 women die from causes related to pregnancy or childbirth. Since 1952 the Confidential Enquiry of Maternal Deaths Reports (CEMD) have collected and analysed data on maternal mortality in the United Kingdom and Northern Ireland. This publication analyses the CEMD from 1985-2013 regarding anaesthesia- and analgesia related maternal deaths during pregnancy or peripartum. During this period, there has been a reduction in directly anaesthesia-related maternal deaths to 4.3%. Yet, an increase in anaesthesia-associated maternal deaths has been recorded. The rate of fatal complications during obstetric regional anaesthesia doubled in recent years, while the fatality risk for obstetric general anaesthesia has decreased. Many of the reported maternal deaths could presumably have been avoided. The anaesthesiologist has to be familiar with state-of-the-art, guideline-based concepts for anaesthesia during pregnancy, childbirth or post partum, especially using tools like simulation. Vital sign monitoring after obstetric anaesthesia has to be identical to other postoperative monitoring, and Modified Early Warning Scores should be used for this purpose. In regional anaesthesia, current standards for hygiene have to be adhered to and patients have to be visited after spinal/epidural anaesthesia. Interdisciplinary communication and collaboration still have to be improved; careful interdisciplinary planning of childbirth in high-risk obstetric patients is strongly advised.

[Anesthesia in obstetrics: Tried and trusted methods, current standards and new challenges]. / Anästhesie in der Geburtshilfe: Altbewährtes, gegenwärtige Standards und neue Herausforderungen.

Obstetric analgesia and anesthesia have some specific aspects, which in particular are directly related to pathophysiological alterations during pregnancy and also to the circumstance that two or even more individuals are always affected by complications or therapeutic measures. This review article deals with some evergreens and hot topics of obstetric anesthesia and essential new knowledge on these aspects is described. The article summarizes the talks given at the 16th symposium on obstetric anesthesia organized by the Scientific Committee for Regional Anaesthesia and Obstetric Anaesthesia within the German Society of Anaesthesiology. The topics are in particular, special features and pitfalls of informed consent in the delivery room, challenges in education and training in obstetric anesthesia, expedient inclusion of simulation-assisted training and further education on risk minimization, knowledge and recommendations on fasting for the delivery room and cesarean sections, monitoring in obstetric anesthesia by neuraxial and alternative procedures, the possibilities and limitations of using ultrasound for lumbal epidural catheter positioning in the delivery room, recommended approaches in preparing peridural catheters for cesarean section, basic principles of cardiotocography, postoperative analgesia after cesarean section, the practice of early bonding in the delivery room during cesarean section births and the management of postpartum hemorrhage.

The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015).

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.

[Manchester triage system. Process optimization in the interdisciplinary emergency department]. / "Manchester Triage System". Prozessoptimierung in der interdisziplinären Notaufnahme.

After formal reorganization of the emergency department of the St. Vincenz Krankenhauses, Limburg, a change in the patient admission process was accomplished. The aim was to improve patient satisfaction and treatment quality by optimizing personnel, diagnostic and spatial resources. In particular the focus was on shifting the initial assessment of treatment priority to the nursing staff. A structured primary assessment triage system (Manchester triage system, MTS) was implemented by which a symptom-based prioritization of patients into five categories can be achieved. In parallel with the development and installation of a software program linking computer-based MTS classifications to defined clinical pathways and diagnostic procedures, a standardized, documented assessment of treatment priority could be achieved in 95% of emergency patients. On average the time between patients' first contact with the nursing staff and treatment by a physician was shortened from 15 to 10 min. Using this standardized, documented and user-independent triage system, medical as well as forensic safety of the admission process in an emergency department was improved.

[Management of hemostasis disorders after extracorporeal circulation. A clinical therapy algorithm]. / Gerinnungsmanagement bei Eingriffen mit extrakorporaler Zirkulation. Klinischer Therapiealgorithmus.

After cardiac surgery with extracorporeal circulation, approximately 20% of patients show significant bleeding tendencies and 5% require re-intervention. In 50% of patients undergoing re-operation, no surgical cause can be determined, suggesting coagulopathy after cardiopulmonary bypass (CPB). For perioperative management of transfusion of blood products and coagulation factor concentrates, a clinical algorithm for the perioperative hemostatic therapy in patients undergoing cardiac surgery with CPB has been developed. The currently available evidence and the point of care methods routinely accessible in our institution (blood gas analysis, ACT, point of care Quick value, aPTT and platelet count) were used. The intervention with plasma products, coagulation factor concentrates and hemostatic drugs after extracorporeal circulation are described. Extensive bleeding history as well as the efficacy and side effects of antifibrinolytic treatment are discussed.

[Anesthetic management of parturients with pre-eclampsia and eclampsia]. / Anästhesie bei Patientinnen mit Präeklampsie und Eklampsie.

Preeclampsia is a pregnancy-associated illness affecting multiple organ systems. Symptoms typically occur after the 20th week of gestation and consist of hypertension (>140/90 mmHg) and proteinuria (>300 mg/day). It is one of the leading causes of premature birth worldwide and early diagnosis and treatment are essential for both fetal and maternal health. Therapy is aimed at lowering blood pressure sufficiently to prevent the most severe complications such as intracranial hemorrhages. At the same time attention must be paid to the possible untoward effects of blood pressure medications on uteroplacental perfusion and fetal well being. Magnesium is the cornerstone for both prevention and control of eclamptic cerebrovascular events. In cases of severe preeclampsia and eclampsia prompt delivery is indicated, often carried out by Cesarean section (>34 weeks of gestation). Compared to general anesthesia, regional anesthesia techniques offer certain advantages to both mother and fetus and in the absence of contraindications are the methods of choice.

[Cardiac perforation after vertebroplasty]. / Palacos im Herzen.

For more than 20 years percutaneous vertebroplasty has been used in the minimally invasive treatment of vertebral fractures. We report on a patient with embolisation of bone cement into the pulmonary artery and the right ventricle, which was perforated. The final diagnosis was delayed due to a combination of complications, previous disorders as well as a second embolisation.

[Levobupivacaine for parturients undergoing elective caesarean delivery. A dose-finding investigation]. / Levobupivacain zur Spinalanästhesie bei der Sectio caesarea. Eine Dosisfindungsuntersuchung.

BACKGROUND: The optimum intrathecal dose of hyperbaric levobupivacaine for spinal anaesthesia during elective caesarean section has not yet been investigated. METHODS: A total of 30 parturients undergoing elective caesarean section were included in this prospective, randomised, double-blind study. Parturients received either 7.5, 10 or 12.5 mg hyperbaric 0.5% levobupivacaine intrathecally. Analgesic, sensory and motor block characteristics as well as maternal and fetal levobupivacaine plasma concentrations were determined. RESULTS: Of the parturients receiving 7.5 mg levobupivacaine 40% required supplementary intravenous opioid analgesics intraoperatively and none achieved complete motor block. Compared to 7.5 mg levobupivacaine, 10 and 12.5 mg significantly prolonged duration of effective analgesia postoperatively (median: 45 vs. 81 and 96 min, respectively). Both maternal and fetal levobupivacaine plasma concentrations were low, with dose-dependent, statistically significant differences in maternal plasma concentrations. CONCLUSIONS: Levobupivacaine 7.5 mg did not provide satisfactory intraoperative analgesia in all parturients. There were no statistically significant differences between 10 and 12.5 mg levobupivacaine with respect to analgesic, sensory and motor block characteristics. Therefore, based on these data, 10 mg levobupivacaine is recommended for parturients undergoing elective caesarean section with spinal anaesthesia.

[Aprotinin in cardiac surgery: more risks than usefulness?]. / Aprotinin in der Kardiochirurgie: Mehr Risiko als Nutzen?

Antifibrinolytic therapy with the serine protease inhibitor Aprotinin or the lysine analogues epsilon-aminocapronic acid or tranexamic acid is a therapeutic measure to reduce perioperative blood loss during cardiac surgery. In an international, prospective, non-randomised phase 4 observation study, Mangano et al. investigated the effectiveness and side-effects of Aprotinin, epsilon-aminocapronic acid and tranexamic acid in comparison to no antifibrinolytic therapy in a total of 4,374 patients who underwent cardiac surgery with extracorporeal circulation. In the opinion of Mangano et al. the results of this study question the safety and effectiveness of Aprotinin for reduction of perioperative blood loss by cardiac surgery patients. Despite a critical review of the study and results reported by Mangano et al., the authors of the present paper come to the conclusion that, in view of the availability of more reasonably priced alternatives in Germany, it appears to be sensible to give preference to tranexamic acid instead of aprotinin.

[Management of HIV-positive pregnancies -- results from a retrospective study]. / Geburtshilfliches Management bei HIV-positiven Schwangeren: Ergebnisse einer retrospektiven Analyse an einem integrativen Zentrum.

OBJECTIVE: The management of HIV-positive pregnancies was investigated in conjunction to pre-, peri and postpartal complications and the HIV transmission rate. PATIENTS AND METHODS: Retrospective study of 88 HIV-positive patients who were delivered at the Dept. of Obstetrics and Gynaecology during 1.1.1997-31.12.2001. RESULTS: HIV-positive patients showed significantly more prepartal complications, compared to control group. Low CD4-cell count (< or = 200/microl) or high viral load (> 10 000 HIV-copies/ml) was not associated with increased risk for transmission relevant complications. The overall HIV-transmission rate was 3.4 % (3/89 newborns; with ART 2.5 % [2/85], without ART 33.3 % [1/3]). The transmission rate increased with complications during pregnancy (7.7 % [2/26] vs. 1.6 % [1/61]). Newborns delivered < or = 35 (th) week of gestation showed a transmission rate of 5.3 % compared to 2.9 % of newborns delivered after the 35 (th) week of gestation. 98 % of the patients were delivered by cesarean section (primary: n = 71, prior: n = 15), spontaneously: n = 2). 97 % of patients (85/88) were treated with antiretroviral therapy (ART). No differences were found in the postpartal complication rate of HIV-positive to -negative patients. None of the newborns was breast fed. CONCLUSIONS: Treatment of this risk-pregnancies in HIV experienced centers significantly reduces the risk of HIV transmission.

[The Anaesthesiological Questionnaire for patients in cardiac anaesthesia. Results of a multicenter survey by the scientific working group for cardiac anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine]. / Der Anästhesiologische Nachbefragungsbogen für Patienten in der Herzanästhesie. Ergebnisse einer Multizentererhebung des wissenschaftlichen Arbeitskreises Kardioanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin.

OBJECTIVE: The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire was adapted for use in cardiac anaesthesia (ANP-KA). The study was conducted to show the value of ANP-KA as a practicable means of assessing the patient's state after cardiac anaesthesia and for its use in quality assurance. METHODS: A total of 1,688 patients from 19 clinics were included who had exclusively received heart valve surgery, CABG surgery or both operations. They completed the ANP-KA between days 1 and 8 postoperatively. RESULTS: The ANP-KA was completed by 79.1% of the patients without any assistance. The highest incidence rates were reported for a dry mouth/thirst (85.1%) and for pain in the area of surgery (60.2%). Plausible and significant differences in patients' symptoms between the grading for the immediate postoperative period and the current state at filling in the questionnaire were found. Women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with anaesthesiological care and convalescence. More complaints were reported after heart valve surgery than after CABG and satisfaction with convalescence was significantly lower after heart valve surgery. The clinics differed with respect to the reported somatic complaints and satisfaction scales. CONCLUSION: The results demonstrate the practicability and validity of the ANP-KA for the assessment of postoperative complaints and patient satisfaction after cardiac surgery.

Comparison of continuous background infusion plus demand dose and demand-only parturient-controlled epidural analgesia (PCEA) using ropivacaine combined with sufentanil for labor and delivery.

BACKGROUND: Using ropivacaine combined with sufentanil, we determined the analgesic efficacy of parturient-controlled epidural analgesia (PCEA) with or without (demand-only PCEA) continuous background infusion in reducing labor pain in 66 parturients. METHODS: After placement of the epidural catheter and administration of an initial bolus containing ropivacaine 16 mg and sufentanil 10 microg, parturients were prospectively randomized into two groups. The PCEA solution consisted of ropivacaine 0.16% plus sufentanil 0.5 microg/mL. Parturients with PCEA plus continuous background infusion received 4 mL/h plus an hourly maximum of three 4-mL boluses on demand (lock-out time 20 min); parturients with demand-only PCEA received an hourly maximum of four 4-mL boluses (lock-out time 15 min) of anesthetic solution. Pain scores (VAS 0-100 mm), drug doses administered, duration of labor, sensory and motor epidural block characteristics, maternal satisfaction, neonatal outcome and adverse events were determined. RESULTS: Both regimens provided excellent parturients' satisfaction and pain relief. However, periods of VAS scores>40 mm during all stages of labor were significantly more frequent in parturients receiving demand-only PCEA (22.4%) compared to parturients receiving PCEA plus continuous background infusion (7.5%, P=0.0011). Drug doses administered, duration of PCEA, labor and delivery, epidural block characteristics, neonatal outcome and adverse events did not differ between groups. CONCLUSION: Under the conditions of the study, PCEA plus continuous background infusion was more effective than demand-only PCEA in treating labor pain without increasing consumption of anesthetic solution.

[Levobupivacaine in obstetric analgesia and anaesthesia. Where is its place?]. / Levobupivacain in der Geburtshilfe. Eine Standortbestimmung.

Levobupivacaine, the S-enantiomer of racemic bupivacaine, will be available in Germany in mid-2004. Pharmacological studies demonstrated that, compared to bupivacaine, levobupivacaine has equal local anaesthetic potency with reduced potential for cardiac and CNS toxicity. This review introduces the new long-acting amide local anaesthetic levobupivacaine to the reader and evaluates its place in obstetric analgesia and anaesthesia compared to bupivacaine and ropivacaine.

[Anesthetic regimen for HIV positive parturients undergoing elective cesarean section]. / Anästhesiologische Versorgung von HIV-positiven Schwangeren zur elektiven Sectio caesarea.

OBJECTIVE: Worldwide, 50 million people are infected with the human immunodeficiency virus (HIV), and 43% are women. Perinatal vertical transmission of HIV accounts for most new pediatric cases. Elective Cesarean delivery, combined antiretroviral therapy perioperatively and abandonment of breast-feeding postoperatively reduces vertical HIV transmission. However, the incidence of maternal and neonatal morbidity perioperatively is relatively unknown. The goal of the present study was to prospectively record perioperative maternal and neonatal complications in the largest HIV positive collective undergoing elective Cesarean section with spinal anesthesia published to date. METHODS: From 1999-2001, 54 HIV positive parturients were enrolled in this study. All parturients received IV zidovudine therapy (2 mg/kg body weight) perioperatively. Spinal anesthesia was performed using 60 mg of 4% hyperbaric mepivacaine plus 5 microg sufentanil intrathecally. Sensory, analgesic and motor block characteristics, the incidence of maternal hypotension, postoperative maternal complications as well as neonatal outcome were recorded. RESULTS: Short-term hypotension occurred in 65% of the parturients. Intraoperatively, one parturient died following amniotic fluid embolism. In 17% of the parturients, postoperative complications headed by wound healing impairment, bronchitis and pneumonia requiring prolonged antibiotic therapy were observed. To date, after a minimum observation period of 8 months, only one infant (1.8%) is HIV positive. CONCLUSION: Intrathecal mepivacaine combined with sufentanil in HIV positive parturients undergoing elective Cesarean section is an appropriate anesthetic option. Postoperative maternal morbidity was 17%. Neonatal outcome showed no evidence of neonatal depression.

Mepivacaine for spinal anesthesia in parturients undergoing elective cesarean delivery: maternal and neonatal plasma concentrations and neonatal outcome.

OBJECTIVE: Worldwide, long-acting bupivacaine is most commonly used for spinal anesthesia in parturients undergoing elective Cesarean delivery. However, advances in surgical technique and shorter duration of surgery make short-acting local anesthetic like mepivacaine appropriate, particularly if combined with opioids to enhance postoperative maternal pain relief. MATERIAL AND METHODS: We assessed the effect of 4% hyperbaric mepivacaine (60 mg) plus 10 microg fentanyl for spinal anesthesia in 11 parturients undergoing elective Cesarean delivery. Sensory, motor and analgesic block characteristics, neonatal outcome (Apgar scores, umbilical cord blood analysis, neurologic and adaptive capacity score) as well as fetal and maternal mepivacaine plasma concentrations at delivery were determined (HPLC/UV). RESULTS: Motor block (Induction-Bromage 0) duration lasted 113 +/- 20 min. Effective analgesia (VAS < or = 40) was 128 +/- 35 min. Maternal and fetal mepivacaine free plasma concentration were 0.18 +/- 0.05 microg/ml and 0.10 +/- 0.03 microg/ml, respectively. The fetal to maternal (UV/MV)-ratio for mepivacaine free plasma concentration was 0.56. Apgar scores, NACScores and the umbilical blood analysis showed no evidence of neonatal depression. CONCLUSIONS: Particularly with short duration of surgery (21 +/- 5 min) intrathecal mepivacaine combined with fentanyl offers a favorable clinical alternative in parturients undergoing elective Cesarean delivery.

[Preoxygenation with the NasOral((R)) system or the standard face mask?]. / Präoxygenierung mit NasOral((R))-System oder herkömmlicher Gesichtsmaske?

INTRODUCTION: Adequate preoxygenation of patients before onset of apnea for orotracheal intubation is of major importance in general anaesthesia. Various preoxygenation techniques are available but a face mask providing an oxygen supply via the circle absorber system of a mechanical respirator is most frequently used. Recently, a new device for preoxygenation - the NasOral((R)) system - has become available. The aim of the present study was to compare the efficacy of intrapulmonary oxygen storage with either the NasOral((R)) device or the standard face mask. METHODS: After informed and written consent and ethics committee approval was obtained, 40 elective patients (ASA I and II) undergoing surgical procedures of the neck and mouth area, were enrolled in this randomized, prospective study. In group A ( n=20), preoxygenation was performed using the NasOral((R)) system. Patients inhaled 100% oxygen through the nose and exhaled orally through unidirectional valves. In group B ( n=20), a conventional face mask with an O(2) flow of 15 l/min and an open airway pressure release valve was used for preoxygenation. In both groups preoxygenation lasted for 2.5 min. Induction of general anaesthesia was performed in a standardized manner. After intubation patients were not ventilated until the O(2) saturation in pulse oximetry (psaO(2)) dropped to 95%. This time of apnea was recorded in both groups and we determined the hemoglobin concentration (cHb) after beginning of ventilation. RESULTS: There were no significant differences with regard to demographic data and cHb. Time of apnea leading to a O(2) saturation of 95% was 6.0+/-2.1 min in group A and 6.3+/-2.1 min in group B (mean+/-SD, p>0.05). CONCLUSIONS: Both the NasOral((R)) system and the face mask are effective for intrapulmonary oxygen storage. In both systems the O(2) flow has to be adequately high and the masks have to be held tightly in order to avoid any contamination of the inhaled oxygen with nitrogen. Due to its unidirectional flow, the NasOral((R)) system additionally requires the patient to be cooperative. As the NasOral((R)) system is more expensive and has no clinical advantages without apneic oxygenation, we prefer the standard face mask for patient preoxygenation.

[Coronary bypass operation with complete median sternotomy in awake patients with high thoracic peridural anesthesia]. / Koronare Bypassoperation mit kompletter medianer Sternotomie am wachen Patienten in hoher thorakaler Periduralanästhesie.

OBJECTIVE: High thoracic epidural anesthesia (TEA) combined with general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques have rendered the use of TEA alone in conscious patients possible and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization the heart is usually approached via median sternotomy, therefore the use of TEA alone was applied in awake patients with multi-vessel coronary artery disease who underwent CABG via median sternotomy. METHODS: A total of 10 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at T1/2 or T2/3. Total arterial myocardial revascularization was performed after median sternotomy. In addition to standard monitoring, anesthetic sensory and motor block levels were determined using an epidural scoring scale for arm movements (ESSAM). RESULTS: Except for one patient who required intraoperative endotracheal intubation due to a pneumothorax, all patients were awake and maintained spontaneous breathing during the entire procedure. Compared to baseline values, hemodynamic parameters, e.g. arterial blood pressure (SAP, MAP, DAP) and heart rate significantly declined during coronary anastomosis. No significant hypercarbia was observed. The intraoperative pain level was subjectively estimated by the patients as less than 20 out of 100 (median 10.95% confidence interval 4.2-21.6) using a visual analogue scale. All patients rated TEA as "good" or "excellent." Adverse effects associated with TEA were not observed. CONCLUSIONS: We could demonstrate that the use of TEA alone for CABG via median sternotomy was feasible and produced good results. High patient satisfaction in our small and highly selected cohort could be reported. Nevertheless, randomized controlled trials in large cohorts are mandatory to definitively evaluate the role of TEA alone in cardiac surgery.