[Telemedical anesthesia consent - Are the patients ready for it? : A comparative requirement analysis before and during the pandemic]. / Telemedizinische Narkoseaufklärung ­ Sind Patienten bereit dafür? : Eine vergleichende Bedarfsanalyse vor und während der Pandemie.

BACKGROUND: Comprehensive anesthesia preparation by means of the anamnesis and physical examination is considered an essential part of the quality criteria for anesthesia. Especially due to the shortage of specialists, there are usually long waiting times in anesthesia outpatient departments and patients must frequently return in cases of missing or pending findings. Telemedicine already offers alternatives in the context of video communication. These alternatives are now particularly prominent due to the currently existing COVID-19 pandemic and the resulting recommendations for digitalization. OBJECTIVES: This comparative cross-sectional study was carried out to show via a patient survey which patient groups are suitable for a telemedical anesthesia preparation and whether the patients are already technically sufficiently equipped. MATERIAL AND METHODS: For this purpose, a total of 2080 patients (1030 before and 1050 during the pandemic) were interviewed using a questionnaire. For matched paired analyses, 630 pairs were formed according to their age and gender. RESULTS: Before and after the pandemic, there was an increase in the percentage of patients already using video communication in their daily lives (30.4% vs. 41.8%). Before the pandemic, 31.7% of patients indicated that they considered this concept of communication to be a practical and appropriate method for an educational conversation and after the pandemic this number increased to 46.6%. For the majority of patients personal contact with a local anesthesiologist was important (80.7% before vs. 67.4% during the pandemic). The number of patients who had the necessary technical equipment for video communication also increased as a result of the COVID-19 pandemic (50.4% vs. 58.2%). DISCUSSION: Almost half of the patients already seem to be open to a telemedical preoperative evaluation. As digitalization progresses, older generations are more likely to recognize the benefits and be able to own and use the necessary technology in the near future. User acceptance should be the central goal of concept development. This must be followed by a randomized controlled study to evaluate the potentials but also the problems in the perioperative process.

[Frailty as potential indicator of perioperative risk for older patients]. / "Frailty" als potenzieller Indikator des perioperativen Risikos alter Patienten.

BACKGROUND: Physical, cognitive and social frailty is increasingly being recognized as a prognostic factor in the perioperative treatment of older patients; however, the concept of frailty has not been introduced into clinical routine in anesthesia. OBJECTIVES: Definition of terms, presentation of tools for determining the degree of frailty and measures to improve the clinical outcome of patients at risk. Proposal of a pragmatic approach for the detection and treatment of high-risk patients in everyday clinical practice. MATERIAL AND METHODS: Evaluation of current reviews and original publications. Discussion and modification of established frailty assessment tools in context of the needs in perioperative medicine. RESULTS: The degree of frailty is associated with the postoperative outcome. Depending on the definition used, the term frailty refers to a degraded resilience in the physical, mental or social domain. Although there is still no universal definition of frailty, it is clear that frailty is directly correlated with survival and postoperative morbidity. Classical perioperative risk markers such as age or ASA classification do not reach such high predictive value. For the perioperative screening and evaluation of frail patients, an adapted version of the MAGIC assessment in combination with two signal questions is recommended. The extent of frailty in a patient can be improved by a sufficient diet, by physiotherapeutic exercises and by providing cognitive aids; however, scientific proof that preoperative improvement of the frailty status subsequently improves postoperative results is available for only a few specific clinical conditions. CONCLUSION: In contrast to commonly used perioperative risk classifications, frailty is a sensitive marker for the patient's biological age. Therefore, it appears more suitable for estimating the perioperative risk than chronological age or other conventional tools, such as the ASA classification and is therefore a prerequisite for patient centered treatment pathways.

[Mechanical circulatory support in terminal heart failure]. / Die mechanische Kreislaufunterstützung in der Herzinsuffizienz.

BACKGROUND: After exhaustion of all conservative measures in the treatment of acute and chronic heart insufficiency, there is the possibility to temporarily or permanently support or replace the pump performance of the heart by mechanical circulatory support (MCS) systems. OBJECTIVE: Presentation of the most important cardiac support systems for intensive care medicine, their indications and important risk factors. MATERIAL AND METHODS: Critical review of device manufacturer's specifications, current research and expert opinions. RESULTS: The spectrum of available MCS procedures include mechanical chest compression devices, catheter-based micropumps and complete artificial hearts. Device selection depends on the severity of heart failure (monoventricular or biventricular pump failure), the expected duration of treatment and the degree of lung function impairment. The decision between minimally invasive and open surgical procedures depends on the options established at the specific healthcare institution and whether the heart function is to be temporarily or permanently replaced. Compliance with the anticoagulation regimens defined by the manufacturer is especially important as they differ vastly between devices and are critical to avoid bleeding or thromboembolic complications. CONCLUSION: Due to the increasing number of patients on long-term mechanical circulatory support, the chances are that physicians in the initial emergency admission are unfamiliar with these devices but need to operate them in emergency cases. Therefore, knowledge of these procedures and their complications becomes increasingly important.

[Heart in sepsis : Molecular mechanisms, diagnosis and therapy of septic cardiomyopathy]. / Herz in der Sepsis : Molekulare Mechanismen, Diagnose und Therapie der septischen Kardiomyopathie.

An impairment of cardiac function is a key feature of cardiovascular failure associated with sepsis; however, its clinical relevance is still underestimated. Recent advancements in echocardiography in patients with septic shock enable a better characterization of septic cardiomyopathy by unmasking a severe, cardiac dysfunction even in the presence of preserved left ventricular ejection fraction. The pathophysiology of septic cardiomyopathy involves a complex mixture of systemic factors and molecular, metabolic, and structural changes of the cardiomyocytes. A better understanding of these factors will enable the discovery of new therapeutic targets for urgently needed disease-modifying therapeutic interventions. To date, the cornerstone of therapeutic management lies in control of the underlying infectious process and hemodynamic stabilization. This review summarizes the pathogenesis, diagnosis, and treatment of septic cardiomyopathy, and highlights the importance of further urgently needed studies aimed at improving diagnosis and treatment for septic cardiomyopathy.

External chest compressions using a mechanical feedback device : cross-over simulation study.

BACKGROUND: External chest compressions (ECC) are essential components of resuscitation and are usually performed without any adjuncts in professional healthcare. Even for healthcare professionals during in-hospital and out-of-hospital resuscitation poor performance in ECC has been reported in recent years. Although several stand-alone devices have been developed none has been implemented as a standard in patient care. The aim of this study was to examine if the use of a mechanical device providing visual feedback and audible assistance during ECC improves performance of healthcare professionals following minimal and simplified instructions. METHODS: In a prospective, randomized cross-over study 81 healthcare professionals performed ECC for 3 min (in the assumed setting of a secured airway) twice on a manikin (Skillreporter ResusciAnne®, with PC-Skillreporting System Version 1.3.0, Laerdal, Stavanger, Norway) in a mock cardiac arrest scenario. Group 1 (n=40) performed ECC with the device first followed by classic ECC and group 2 (n=41) in the opposite order. Minimal instructions were standardized and provided by video instruction (1 min 38 s). Endpoints were achievement of a mean compression rate between 90 and 110/min and a mean compression depth of 40-50 mm. In addition participants had to answer questionnaires about demographic data, professional experience and recent recommendations for ECC as well as their impression of the device concerning the ease of use and their personal level of confidence. Data were analyzed for group-related and inter-group differences using SAS (Version 9.1.3, SAS Institute, Cary, NC). RESULTS: A total of 81 healthcare professionals regularly involved in resuscitation attempts in pre-hospital or in-hospital settings took part in the study with no differences between the groups: females 35.8% (n=52), emergency medical technicians 32.1% (n=26), anesthesia nurses 32.1% (n=26), physicians (anesthesiology) 45% (n=29). In group 1 33 out of 40 (82.5%; 99.7±4.82/min; 95% confidence interval 95% CI: 98.1-101.2/min) reached the correct range for compression rate and 29/40 (72.5%; 44.0±4.95 mm; 95% CI: 42.4-45.6 mm) the correct compression depth using the assisting device. Afterwards they conducted classic ECC without the device and deteriorated significantly: correct compression rate was achieved by 12/40 (30%, p≤0.0001; 110.6±11.0/min (95% CI: 107.1-114.1/min), while 25/40 (62.5%; 44.5±5.63 mm; 95% CI: 42.6-46.3 mm) met the correct compression depth. Group 2 performed poorer in ECC without assistance and 5/41 (12.2%; 104.5±21.35/min; 95% CI: 97.8-111.3/min) reached the correct rate whereas 21/41 (51.2%; 39.6±7.61 mm; 95% CI: 37.2-42.0 mm) compressed to the appropriate depth. Using the device there was a significant improvement in the second evaluation with 34/41 (82.9%, p≤0.0001; 101.7±4.68/min; 95% CI: 100.2-103.2/min) reaching the correct rate and 36/41 (87.8%, p≤0.0001; 43.9±4.16 mm; 95% CI: 42.6-45.2 mm) the correct depth. CONCLUSIONS: The tested device is easy to use after instruction of less than 3 min and improves ECC performance of healthcare professionals in simulated cardiac arrest with respect to compression depth as well as compression rate.

Xenon: recent developments and future perspectives.

The noble gas xenon exerts favorable anesthetic properties along with remarkable hemodynamic stability in healthy patients undergoing elective surgery. Recent investigations documented that it does not prolong the duration of widely used neuromuscular blocking agents, including mivacurium and rocuronium. Some studies also suggest reduced neurocognitive compromise in the very early phase after general anesthesia. These properties differ from those observed for conventional inhalational anesthetics like isoflurane, desflurane and sevoflurane. However, a wider use of xenon in daily clinical routine has been limited owing to its higher price and technical restraints regarding economic delivery. Although there are controversial opinions, xenon seems to exert its main anesthetic features via the glutamate receptor. Recently, a novel binding cavity on the NMDA-subtype glutamate receptor has been elucidated that is occupied by xenon as well as isoflurane. Studies utilizing advanced imaging technologies have furthermore revealed that xenon markedly suppresses cerebral blood flow and glucose metabolism in distinct regions of the human brain. These investigations promise to further the understanding of the basic mechanisms underlying the induction and maintenance of anesthesia in general. Results from in vitro studies and various animal models have consistently demonstrated organoprotective properties of xenon, mainly in settings of ischemia and reperfusion injury. Interestingly, these effects have frequently been observed at subanesthetic concentrations and seem to be synergistic when used in combination with therapeutic hypothermia. Future studies will have to prove whether the high costs of xenon administration might be outweighed by its ability to substantially reduce the sequelae of myocardial and cerebral ischemia.