Der Anaesthesist
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Catheter-guided interventional implantation of cardiac valves is one of the main developments in cardiology over the past 15 years. It is characterized by a close interdisciplinary cooperation in the heart team (H-team), which consists of cardiac anesthesiologists, cardiologists and heart surgeons. This co-responsibility for anesthesia, which is demanded by the legislator (Federal Joint Committee, G‑BA, July 2015), includes not only qualified training for the cardiac anesthesiologist, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) but also several years of experience in cardiac anesthesia and correlates with the recommendations of the German Society for Anaesthesiology and Intensive Care Medicine. ⋯ This article discusses the interventional procedures of heart valvular diseases as well as the hemodynamic changes associated with the procedures from the anesthesiologist's point of view. To present examples, we have selected transcatheter aortic valve replacement (TAVR) and the interventional procedure of mitral and tricuspid valve insufficiency called MitraClip and TricaClip. A thorough examination of the procedural risk rate shows that despite minimizing the surgical intervention by miniaturizing the devices, the presence of an experienced cardiac anesthesiologist is obligatory.
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A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL‑6 receptor antagonist tocilizumab was initiated. ⋯ Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.
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Sepsis-associated encephalopathy (SAE) is one of the most frequent causes of neurocognitive impairment in intensive care patients. It is associated with increased hospital mortality and poor long-term neurocognitive outcome. To date there are no evidence-based recommendations for the diagnostics and neuromonitoring of SAE. ⋯ This explorative survey demonstrated a great heterogeneity in diagnostics and neuromonitoring of SAE in German ICUs. Uniform concepts have not yet been established but are desired by the majority of study participants. Innovative biomarkers of neuroaxonal injury in blood and cerebrospinal fluid as well as electrophysiological and brain imaging techniques could provide valuable prognostic information on the neurocognitive outcome of patients and would thus be a useful addition to the clinical assessment of ICU patients with SAE.
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Pulmonary aspiration of solid components leads to displacement of the tracheobronchial tree, the aspiration of acidic gastric juices to chemical pneumonitis (Mendelson's syndrome) and the aspiration of oropharyngeal secretions or gastrointestinal pathogens to aspiration pneumonia. Principally, pulmonary aspiration can occur at any stage of anesthesia. ⋯ If severe pulmonary aspiration occurs despite all preventive measures, mostly during induction of anaesthesia, extensive experience and rapid action are necessary. This can only be achieved if the induction to RSI is performed by three persons with supervision of the trainee anaesthetist by a consultant anaesthetist.