Der Anaesthesist
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The introduction of routine prenatal screening using ultrasound has led to a substantial increase in diagnoses of fetal disorders that are amenable to intrauterine treatment. While an ultrasound guided insertion of small bore cannulas can be performed under local anesthesia, insertion of a fetoscope usually requires anesthetic management for the mother and the fetus. Additionally, the fetus' intrauterine position may have to be manipulated in order to enable access. Such manoeuvres depend on relaxation of the mother's abdominal wall. General anesthesia has been the preferred method, but it involves substantial risks both to the mother and possibly the fetus, especially when combined with aggressive uterine relaxation. Epidural anesthesia (EA) may provide an alternative. Only little systematic data on the efficacy, requirements or untoward effects of epidural anesthesia for fetoscopy exists in the literature, yet a high rate of arterial hypotension following EA has been reported. We therefore aimed to assess the hemodynamic reaction to EA in a mixed population of pregnant women undergoing fetoscopy for a variety of fetal conditions and performed a retrospective analysis of a one-year cohort in a single university hospital. ⋯ This retrospective study demonstrates that fetoscopic procedures under EA in the range of indications treated in our institution can be performed safely. EA was associated with stable hemodynamic conditions in this mixed cohort of pregnant women. EA appears thus to be a suitable technique for fetoscopy, avoiding the risks inherent to general anesthesia in pregnant women.
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Emergency ultrasound as part of the provision of emergency medical services using mobile devices offers great benefits regarding to some important questions related to the management of critically ill and injured patients in the prehospital situation where diagnostic resources are limited. The aim of this study is to determine whether the comprehensive introduction of prehospital emergency ultrasound examinations into a German Emergency Medical Services ("rescue services") area is both feasible and beneficial for patients. ⋯ Prehospital emergency ultrasound can be introduced into an emergency medical service area as a diagnostic modality that provides benefits to patients. Emergency physicians have to be specifically trained and to participate in continuous education activities. Especially in rural areas with longer transport routes and journey times, the early diagnosis of for example massive intra-abdominal bleeding is critical for the patient's prognosis.
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Simulation has been increasingly used in medicine. In 2003 German university departments of anesthesiology were provided with a full-scale patient simulator, designated for use with medical students. Meanwhile simulation courses are also offered to physicians and nurses. Currently, the national model curriculum for residency programs in anesthesiology is being revised, possibly to include mandatory simulation training. ⋯ Important first steps have been taken to implement full-scale simulation in Germany. In addition to programs for medical students courses for physicians and nurses are available today. To reach everyone clinically involved in German anesthesiology on a regular basis the current capacities need to be dramatically increased. The basis for that to happen will be new concepts for funding, possibly supported by external requirements such as the national model curriculum for residency in anesthesiology.
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Robert Bartlett, emeritus Professor of surgery at the University of Michigan in Ann Arbor, USA, transformed classical works of world literature (Charles Dickens: A Christmas Carol, Lewis Carroll: Alice in Wonderland) into teaching aids for advanced training in intensive care medicine. He recently turned his hand to the well-known work of Ernest Hemingway: the Nobel Prize winning novel The Old Man and the Sea. Subsequent to Robert Bartlett's essay this article provides background information and comments on the current problems in modern intensive care medicine addressed in his essay.