Der Anaesthesist
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Anesthesia services outside central surgical facilities (nonoperating room anesthesia, NORA) have become more important. Nonoperating room anesthesia is a challenging field with a wide range of patient ages and interventions. The anesthesiologist is caught between the existing expertise in sedation, respiratory and emergency management and the fact that it may be a potentially avoidable cost factor. ⋯ Only in this way can the participating specialist disciplines be convinced of the anesthesiological added value for the patient. Groups of patients requiring special attention include pediatric patients. The care especially for children under 2 years old also requires the particular anesthesiological expertise of the supervising anesthesiologist; however, profound knowledge, for example in cardiac anesthesia, is also required if special interventions are decentrally managed in the cardiac catheterization laboratory.
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Sonographically controlled blockade of the distal sciatic nerve is usually performed by placing the ultrasound probe on the dorsal side of the thigh. This requires positioning maneuvers (prone or side positioning) of the patient as well as additional assistance. In order to avoid these positioning maneuvers, a positioning aid with integrated ultrasound probe holder has been developed and its practicability was examined on patients with lower limb surgery. ⋯ A total of >100 patients were treated, who underwent elective lower leg, ankle or foot surgery with a continuous blockade of the distal sciatic nerve using catheters for postoperative analgesia. The advantages are easy performance, hands-free needle movement and catheter placement. The disadvantages might be the need for in-plane catheter placement and a fixed ultrasound angle.
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Besides very low depth of anesthesia (DOA) index values, special intraoperative electroencephalography (EEG) patterns, such as burst suppression patterns and the correlation with postoperative delirium and mortality have been examined. Over the last decade the 13 studies described in this article yielded information that documented low DOA indices or burst suppression patterns increased the risk of either postoperative cognitive dysfunction or mortality; however, these were mainly secondary data analyses or retrospective observational studies. ⋯ Meanwhile, the first prospective interventional studies on avoidance of excessive EEG suppression are currently in progress. The results would not only enable the formulation of evidence-based recommendations but should also provide indicatíons and references as to whether the above mentioned observations can be explained by a causal association or an epiphenomenon.
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Idiopathic achalasia is a motility disorder of the esophagus characterized by a dysfunction of the lower esophageal sphincter, which typically manifests as dysphagia. Peroral endoscopic myotomy (POEM) is an interventional endoscopic procedure for achalasia, which was introduced in 2010. Although results from randomized studies comparing short-term and long-term safety and efficacy are yet to be published, POEM is regarded to be less invasive than the standard treatment of achalasia (laparoscopic Heller myotomy). ⋯ The POEM procedure is a therapeutic innovation and interdisciplinary challenge. However, anesthesia standards of care have not yet been specified. The aim of this review is therefore to outline some clinical recommendations for the daily clinical practice based on existing evidence.
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In emergency situations it is essential to get access to medical treatment as early as possible. In Germany, the time interval from alarm to arrival should be less than 10-15 min. The emergency medical service (EMS) cannot comply with this recommendation in approximately 10% of the emergencies in Baden-Württemberg. In addition to the traditional EMS system, a voluntary system of first responders has been developed over the last years to reduce this interval. They are incorporated into the alarm system of the traditional EMS and are alarmed as soon as an emergency call arrives. Data on process times (from alarm to begin of treatment or duration of treatment until arrival of EMS) and quality are rare. In Baden-Württemberg, the emergency aid "Deutsche Lebens-Rettungs-Gesellschaft e.V. (DLRG)" Nordhardt can only estimate times and quality of primary care. The objective of this analysis was to describe and evaluate such a first responder system. ⋯ The first responders from Nordhardt received an emergency call nearly every day. In two thirds of the calls they were faster than the EMS as they usually have local sites with a shorter distance to the emergency scene where they are able to deal with critical medical cases until the EMS arrives. Despite the small case numbers, it could be concluded that the early medical treatment with respect to resuscitation based on earlier arrival on site may help to increase the survival rate of patients. The first responders were also able to manage airway problems with additional oxygen or other airway devices. Other medical treatment performed by the first responders, such as administration of glucose in hypoglycemic patients positively affected the patient's condition. There is a tactical advantage to include first responders in traditional EMS services. Further studies are needed to examine these questions in larger samples also over a longer time period. Standardization and digitalization of the records could help to gain more data in this field.