Der Anaesthesist
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At the 121st German Physicians Conference 2018 in Erfurt a resolution to accept the full amendment of the (draft) further training regulations (MWBO) was adopted and the State Medical Councils were requested to include them in their respective areas of responsibility. Therefore, the nationwide implementation of the supraspeciality (ZWB) for clinical acute and emergency medicine has been officially finalized. After consultation with the German Medical Council (BÄK) concerning the format, both the new MWBO 2018 and now the content of the ZWB are available as of 15 November 2018. ⋯ In addition to the title, definition, and minimum requirements for applying the ZWB, the content was processed according to the European curriculum for emergency medicine. The structural prerequisites have now been approved, the Standing Committee has configured the content, and the complete MWBO 2018 has been successfully presented, such that the ZWB clinical acute and emergency medicine is expected to be implemented in the individual Federal States within the next 1-2 years. This article describes the history and development of ZWB clinical acute and emergency medicine in Germany and outlines future perspectives.
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Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. ⋯ Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.
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Neurodegeneration with brain iron accumulation (NBIA) forms a group of rare hereditary diseases with rapid neurodegenerative progression due to an abnormal accumulation of iron in the basal ganglia. This causes extrapyramidal symptoms as well as dystonia and mental retardation. The most common form of NBIA is pantothenate kinase-associated neurodegeneration (PKAN, formerly Hallervorden-Spatz syndrome). There are multiple anesthesiological challenges with great implications for the clinical routine, particularly regarding the preparation for general anesthesia and the premedication visits. As with other orphan diseases, the available recommendations are mainly based on case reports. ⋯ The handling of NBIA patients requires good preparation, including an interdisciplinary team and customized time management. In principle, both general anesthesia as a balanced method and total intravenous anesthesia (TIVA) seem to be possible/viable options. The main focus is on airway management. Even after brief sedation in the context of diagnostic measures, the patient should be monitored for longer than usual.
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Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. ⋯ Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.
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Review
[Central venous pressure in liver surgery : A primary therapeutic goal or a hemodynamic tessera?]
Central venous pressure (CVP) is deemed to be an important parameter of anesthesia management in liver surgery. To reduce blood loss during liver resections, a low target value of CVP is often propagated. Although current meta-analyses have shown a connection between low CVP and a reduction in blood loss, the underlying studies show methodological weaknesses and advantages with respect to morbidity and mortality can hardly be proven. ⋯ The definition of a generally valid target area for the CVP must be called into question. The primary objective is to maintain adequate oxygen supply and euvolemia. The CVP should be regarded as a mosaic stone of hemodynamic management.