Thomas Wiesmann

In der peripheren Regionalanästhesie gibt es einige aktuelle Entwicklungen – basierend auf Diskussionen bei Fachveranstaltungen und Anfragen an den Arbeitskreis Regionalanästhesie der DGAI stellt dieser Beitrag sie dar. Relevante Themen sind u. a. die Handhabung antithrombotischer Medikation bei peripheren Blockaden, der Entlasszeitpunkt nach Plexusanästhesien sowie periphere Nervenblockaden unter Allgemeinanästhesie und in der Notfallmedizin. This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA. Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances. Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques. Article published online: 21 March 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Alltag morgens im OP. Die Patientin zur großen viszeralchirurgischen Operation liegt in der Einleitung, für alle notwendigen Dinge (Narkose, Peridural-, zentraler Venenkatheter und invasive Blutdruckmessung) aufgeklärt. Man fahndet nach den aktuellen Laborwerten, denkt über die grenzwertige Nierenfunktion nach und findet in der aktuellen Medikation plötzlich ein direktes orales Antikoagulantium (DOAK). Aber pausiert, seit wann? Ein schüchternes Fragezeichen hinter dem Datum liefert mehr Verunsicherung als Klarheit. Reicht das Pausenintervall für eine PDK-Anlage ohne schlechtes Gewissen? Was nun? Article published online: 06 September 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

BACKGROUND. Results of many randomized trials on COVID-19 convalescent plasma (CCP) have been reported, but information on long-term outcome after CCP treatment is limited. The objectives of this extended observation of the randomized CAPSID trial are to assess long-term outcome and disease burden in patients initially treated with or without CCP. METHODS. Of 105 randomized patients, 50 participated in the extended observation. Quality of life (QoL) was assessed by questionnaires and a structured interview. CCP donors (n = 113) with asymptomatic to moderate COVID-19 were included as a reference group. RESULTS. The median follow-up of patients was 396 days, and the estimated 1-year survival was 78.7% in the CCP group and 60.2% in the control (P = 0.08). The subgroup treated with a higher cumulative amount of neutralizing antibodies showed a better 1-year survival compared with the control group (91.5% versus 60.2%, P = 0.01). Medical events and QoL assessments showed a consistent trend for better results in the CCP group without reaching statistical significance. There was no difference in the increase in neutralizing antibodies after vaccination between the CCP and control groups. CONCLUSION. The trial demonstrated a trend toward better outcome in the CCP group without reaching statistical significance. A predefined subgroup analysis showed a significantly better outcome (long-term survival, time to discharge from ICU, and time to hospital discharge) among those who received a higher amount of neutralizing antibodies compared with the control group. A substantial long-term disease burden remains after severe COVID-19. Trial registration. EudraCT 2020-001310-38 and ClinicalTrials.gov NCT04433910. Funding. Bundesministerium für Gesundheit (German Federal Ministry of Health).

Background Acute kidney injury (AKI) is a frequent complication associated with on-pump cardiac surgery. Early recognition may alter their prognosis. Therefore, the urinary concentrations of TIMP-2 (tissue inhibitor of metalloproteinases-2) and IGFBP7 (insulin-like growth factor-binding protein) as predictors for AKI were studied. Methods Repetitive blood and urine samples were collected consecutively from 50 patients. Demographic, intra-, and postoperative data were recorded prospectively. To calculate the production of the TIMP-2 and IGFBP-7 protein concentrations, urinary samples were taken preoperatively, intraoperatively at 30 and 60 min after aortic clamping and at 0, 6, 12, and 24 h after admission to the intensive care unit (ICU). Results AKI occurred in 14 patients (28%), all of them at Kidney Disease: Improving Global Outcomes stage 1. Predictive value for [TIMP-2] × [IGFBP7] was shown at 0 and 24 h after admission to ICU. At 0 h, the sensitivity was 84.6% and the specificity 55.6% for an ideal calculated cutoff at 0.07. After 24 h, the ideal cutoff amounted to 0.35 with a sensitivity of 53.8% and a specificity of 88.2%. The receiver operating characteristic curves demonstrated areas under the curve of 0.725 and 0.718. The suggested cutoffs of 0.3 and 2.0 could not be confirmed. The serum creatinine was reached to the peak median within 48 h after admission to ICU. Conclusion Postoperative risk assessment for the development of AKI can be established by . Previously suggested cutoff values could not be confirmed. A correlation with urinary dilution parameters may enable the identification of more universal cutoffs.

Introduction: Urolithiasis is a common disease leading to a high socioeconomic burden due to treatment costs and sickness leave. The aim of this study was to evaluate recent trends in the incidence of urolithiasis in Germany and in the use of therapeutic interventions. Methods: Treatment data for all in-patient hospital episodes for urolithiasis between 2005 and 2016 were extracted from the national DRG statistics at DESTATIS and analysed with regard to the corresponding procedures according to the OPS code. Results: Incidence for urolithiasis was stable at around 120,000 cases per year during the observation period with a male:female ratio of 2:1. Rising numbers were noted for patients >80 years. Nevertheless, the number of coded procedures rose significantly with a marked disproportionate transition from extracorporeal shock wave lithotripsy towards ureterorenoscopy. Percutaneous nephrolithotomy was performed more frequently on a smaller scale. Discussion/Conclusion: While the global incidence of urolithiasis is still rising, Germany, as other Western countries, has reached a plateau. There is a remarkable trend towards invasive treatment of even asymptomatic kidney stones. Besides the effects on individual patients with increased risk for complications, this results in a higher monetary burden to the health care system and society.

BACKGROUND. COVID-19 convalescent plasma (CCP) has been considered a treatment option for COVID-19. This trial assessed the efficacy of a neutralizing antibody containing high-dose CCP in hospitalized adults with COVID-19 requiring respiratory support or intensive care treatment. METHODS. Patients (n = 105) were randomized 1:1 to either receive standard treatment and 3 units of CCP or standard treatment alone. Control group patients with progress on day 14 could cross over to the CCP group. The primary outcome was a dichotomous composite outcome of survival and no longer fulfilling criteria for severe COVID-19 on day 21. Results. The primary outcome occurred in 43.4% of patients in the CCP group and 32.7% in the control group (P = 0.32). The median time to clinical improvement was 26 days in the CCP group and 66 days in the control group (P = 0.27). The median time to discharge from the hospital was 31 days in the CCP group and 51 days in the control group (P = 0.24). In the subgroup that received a higher cumulative amount of neutralizing antibodies, the primary outcome occurred in 56.0% of the patients (vs. 32.1%), with significantly shorter intervals to clinical improvement (20 vs. 66 days, P < 0.05) and to hospital discharge (21 vs. 51 days, P = 0.03) and better survival (day-60 probability of survival 91.6% vs. 68.1%, P = 0.02) in comparison with the control group. Conclusion. CCP added to standard treatment was not associated with a significant improvement in the primary and secondary outcomes. A predefined subgroup analysis showed a significant benefit of CCP among patients who received a larger amount of neutralizing antibodies. Trial registration. ClinicalTrials.gov NCT04433910. Funding. Bundesministerium für Gesundheit (German Federal Ministry of Health): ZMVI1-2520COR802.

As part of a plethora of global efforts to minimize the negative effects of the SARS-CoV2 (COVID-19) pandemic, we developed two different mechanisms that, after further development, could potentially be of use in the future in order to increase the capacity of ventilators with low-cost devices based on single-use-bag-valve mask systems. We describe the concept behind the devices and report a characterization of them. Finally, we make a description of the solved and unsolved challenges and propose a series of measures in order to better cope with future contingencies.

Zusammenfassung Rumpfblockaden zur Regionalanästhesie haben mit Einführung der Sonographie eine neue Bedeutung erfahren. Durch Umgehung von zu meidenden Begleitstrukturen hilft der Ultraschall, Komplikationen zu vermeiden. Zusätzlich sind komplexe Punktionen möglich, die allein durch Landmarken zu risikoreich wären. Neben der gezielten Blockade einzelner Nervenstrukturen haben sich auch interfasziale bzw. Kompartimentblockaden etabliert, bei denen die Darstellung einzelner Nerven oder Plexusstrukturen nicht von Bedeutung ist. Die vorliegende Übersichtsarbeit beschreibt publizierte und klinisch etablierte Punktionstechniken bezüglich ihrer Indikationen und Durchführung. Es wird erläutert, welchen Stellenwert sie in Bezug auf Wirkungsprofil und klinisch-wissenschaftliche Evidenz haben. Weiterhin erläutern die Autoren mögliche Komplikationen, Risiken und Lokalanästhetikadosierungen.