Neuromonitoring und Neuroprotektion in der Kardioanästhesie: Bundesweite Umfrage des Arbeitskreises Kardioanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V

Zusammenfassung: Fragestellung: Primäres Ziel dieser in deutschen kardioanästhesiologischen Abteilungen durchgeführten Umfrage war, die aktuelle Praxis von Neuromonitoring und Neuroprotektion zu erheben. Methodik: Zwischen Oktober 2007 und Januar 2008 wurden hierzu Daten mithilfe eines 26Punkte umfassenden, anonymisierten Fragebogens erhoben. Ermittelt wurden: präoperative Evaluation der hirnversorgenden Arterien, intraoperatives Neuromonitoring, zerebroprotektive Maßnahmen, Perfusionsmanagement während extrakorporaler Zirkulation, postoperative Erhebung des neurologischen Status und Aus-/Weiterbildung im zerebralen Monitoring. Ergebnisse: 55% der Fragebögen wurden mit folgenden Angaben beantwortet: präoperative Duplexsonographie der Hirngefäße in 90% der Kliniken; intraoperatives Neuromonitoring mithilfe der Elektroenzephalographie (EEG; 60%) bei Typ-A-Dissektionen (38,1%), bei elektiven Operationen an der thorakalen bzw. thorakoabdominellen Aorta (34,1% resp. 31,6%) und in der Karotischirurgie (43,2%), weiterhin Einsatz der Nahinfrarotspektroskopie (40%), Ableitung evozierter Potenziale (30%) und transkranielle Dopplersonographie (17,5%). Auch kombinierte Verfahren wurden angewandt. Während Bypass-, Klappen und minimal-invasiven Operationen erfolgt meistens kein Monitoring des Zentralnervensystems. Zur Zerebroprotektion werden die Kühlung des Patienten an Herz-Lungen-Maschine (HLM; 100%), externe Kühlung des Kopfes (65%), Gabe von Kortikosteroiden (58%), Barbituraten (50%) und Antiepileptika (10%) eingesetzt. Als neuroprotektive Anästhesieverfahren gelten Inhalationsanästhesie (32,5%; Favorit: Sevofluran 76,5%) und total intravenöse Anästhesie (20%; Favoriten: Propofol und Barbiturate mit je 46,2%). Standardmäßig kühlen 72,5% der Krankenhäuser die Patienten bei Operationen mit Herz-Kreislauf-Stillstand, 37,5% bei allen Operationen mit HLM. Unter normothermen Bedingungen entspricht in 84,6% der Kliniken der HLM-Fluss dem errechneten Herzzeitvolumen (HZV), der anzustrebende mittlere arterielle Druck (MAP) liegt bei 60-70mmHg (43,9%) bzw. 50-60mmHg (41,5%). Bei einer Körpertemperatur unter 18°C wird der HLM-Fluss unter das errechnete HZV gesenkt (70%), während in 27% der Kliniken normotherme Flussraten gefahren werden. Der bevorzugte MAP unter Hypothermie liegt zwischen 50 und 60mmHg (59%). Intraoperatives Neuromonitoring wird im Narkoseprotokoll (77%) dokumentiert. Postoperativ wird der neurologische Status in 42,5% der Kliniken durch individuelle Einschätzung des Anästhesisten (77,5%) erhoben. Fortbildungen zum Thema Neuromonitoring werden in 32,5% der Kliniken regelmäßig organisiert, in 37,5% dem Arzt selbst überlassen. Schlussfolgerung: Das kardioanästhesiologische Vorgehen in Deutschland ist im Bereich Neuromonitoring und neuroprotektive Therapie nicht standardisiert. Ein "multimodales Neuromonitoring" wäre wünschenswer

Design and Characterization of an Ethosomal Gel Encapsulating Rosehip Extract

: Rising environmental awareness drives green consumers to purchase sustainable cosmetics based on natural bioactive compounds. The aim of this study was to deliver Rosa canina L. extract as a botanical ingredient in an anti-aging gel using an eco-friendly approach. Rosehip extract was first characterized in terms of its antioxidant activity through a DPPH assay and ROS reduction test and then encapsulated in ethosomal vesicles with different percentages of ethanol. All formulations were characterized in terms of size, polydispersity, zeta potential, and entrapment efficiency. Release and skin penetration/permeation data were obtained through in vitro studies, and cell viability was assessed using an MTT assay on WS1 fibroblasts. Finally, ethosomes were incorporated in hyaluronic gels (1% or 2% w/v) to facilitate skin application, and rheological properties were studied. Rosehip extract (1 mg/mL) revealed a high antioxidant activity and was successfully encapsulated in ethosomes containing 30% ethanol, having small sizes (225.4 ± 7.0 nm), low polydispersity (0.26 ± 0.02), and good entrapment efficiency (93.41 ± 5.30%). This formulation incorporated in a hyaluronic gel 1% w/v showed an optimal pH for skin application (5.6 ± 0.2), good spreadability, and stability over 60 days at 4 °C. Considering sustainable ingredients and eco-friendly manufacturing technology, the ethosomal gel of rosehip extract could be an innovative and green anti-aging skincare product

European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility

It is 30 yr since the British Journal of Anaesthesia published the first consensus protocol for the laboratory diagnosis of malignant hyperthermia susceptibility from the European Malignant Hyperthermia Group. This has subsequently been used in more than 10 000 individuals worldwide to inform use of anaesthetic drugs in these patients with increased risk of developing malignant hyperthermia during general anaesthesia, representing an early and successful example of stratified medicine. In 2001, our group also published a guideline for the use of DNA-based screening of malignant hyperthermia susceptibility. We now present an updated and complete guideline for the diagnostic pathway for patients potentially at increased risk of developing malignant hyperthermia. We introduce the new guideline with a narrative commentary that describes its development, the changes to previously published protocols and guidelines, and new sections, including recommendations for patient referral criteria and clinical interpretation of laboratory finding

Anaesthetic considerations of adults with Morquio's syndrome - a case report

<p>Abstract</p> <p>Background</p> <p>The anaesthetic management of patients with Morquio syndrome is complicated by a number of factors including odontoid hypoplasia, atlantoaxial instability, thoracic kyphosis, and deposition of mucopolysaccharides in the soft tissue of the oropharnyx.</p> <p>Case presentation</p> <p>Herein we describe the anaesthetic considerations and management of a 26 year old adult with Morquio syndrome, who presented for an elective hip replacement.</p> <p>Conclusion</p> <p>This report details an awake fiberoptic intubation in an adult with Morquio syndrome. We recommend that this approach be considered in patients with Morquio syndrome undergoing general anaesthesia.</p

European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility

It is 30 yr since the British Journal of Anaesthesia published the first consensus protocol for the laboratory diagnosis of malignant hyperthermia susceptibility from the European Malignant Hyperthermia Group. This has subsequently been used in more than 10 000 individuals worldwide to inform use of anaesthetic drugs in these patients with increased risk of developing malignant hyperthermia during general anaesthesia, representing an early and successful example of stratified medicine. In 2001, our group also published a guideline for the use of DNA-based screening of malignant hyperthermia susceptibility.We now present an updated and complete guideline for the diagnostic pathway for patients potentially at increased risk of developing malignant hyperthermia.We introduce the new guideline with a narrative commentary that describes its development, the changes to previously published protocols and guidelines, and new sections, including recommendations for patient referral criteria and clinical interpretation of laboratory finding

A reference time scale for Site U1385 (Shackleton Site) on the SW Iberian Margin

Variations in sediment color contain very strong precession signals at Site U1385, and the amplitude modulation of these cycles provides a powerful tool for developing an orbitally-tuned age model. We tuned the U1385 record by correlating peaks in L* to the local summer insolation maxima at 37°N. The benthic δ18O record of Site U1385, when placed on the tuned age model, generally agrees with other time scales within their respective chronologic uncertainties. The age model is transferred to down-core data to produce a continuous time series of log(Ca/Ti) that reflect relative changes of biogenic carbonate and detrital sediment. Biogenic carbonate increases during interglacial and interstadial climate states and decreases during glacial and stadial periods. Much of the variance in the log(Ca/Ti) is explained by a linear combination of orbital frequencies (precession, tilt and eccentricity), whereas the residual signal reflects suborbital climate variability. The strong correlation between suborbital log(Ca/Ti) variability and Greenland temperature over the last glacial cycle at Site U1385 suggests that this signal can be used as a proxy for millennial-scale climate variability over the past 1.5 Ma. Millennial climate variability, as expressed by log(Ca/Ti) at Site U1385, was a persistent feature of glacial climates over the past 1.5 Ma, including glacial periods of the early Pleistocene (‘41-kyr world’) when boundary conditions differed significantly from those of the late Pleistocene (‘100-kyr world’). Suborbital variability was suppressed during interglacial stages and enhanced during glacial periods, especially when benthic δ18O surpassed ~ 3.3–3.5‰. Each glacial inception was marked by appearance of strong millennial variability and each deglaciation was preceded by a terminal stadial event. Suborbital variability may be a symptomatic feature of glacial climate or, alternatively, may play a more active role in the inception and/or termination of glacial cycles

[Neuromonitoring and neuroprotection in cardiac anaesthesia. Nationwide survey conducted by the Cardiac Anaesthesia Working Group of the German Society of Anaesthesiology and Intensive Care Medicine]

OBJECTIVE: The primary objective of this nationwide survey carried out in department of cardiac anesthesia in Germany was to identify current practice with regard to neuromonitoring und neuroprotection. METHODOLOGY: The data are based on a questionnaire sent out to all departments of cardiac anesthesia in Germany between October 2007 und January 2008. The anonymized questionnaire contained 26 questions about the practice of preoperative evaluation of cerebral vessels, intra-operative use of neuromonitoring, the nature und application of cerebral protective measures, perfusion management during cardiopulmonary bypass, postoperative evaluation of neurological status, and training in the field of cerebral monitoring. RESULTS: Of the 80 mailed questionnaires 55% were returned and 90% of department evaluated cerebral vessels preoperatively with duplex ultrasound. The methods used for intra-operative neuromonitoring are electroencephalography (EEG, 60%) for type A dissections (38.1%), for elective surgery on the thoracic and thoraco-abdominal aorta (34.1% and 31.6%, respectively) and in carotid surgery (43.2%) near infrared spectroscopy (40%), evoked potentials (30%) and transcranial Doppler sonography (17.5%), with some centers using combined methods. In most departments the central nervous system is not subjected to monitoring during bypass surgery, heart valve surgery, or minimally invasive surgery. Cerebral protective measures used comprise patient cooling on cardio-pulmonary bypass (CPB 100%), extracorporeal cooling of the head (65%) and the administration of corticosteroids (58%), barbiturates (50%) and antiepileptic drugs (10%). Neuroprotective anesthesia consists of administering inhalation anesthetics (32.5%; sevoflurane 76.5%) and intravenous anesthesia (20%; propofol and barbiturates each accounting for 46.2%). Of the departments 72.5% cool patients as a standard procedure for surgery involving cardiovascular arrest and 37.5% during all surgery using CPB. In 84.6% of department CPB flow equals calculated cardiac output (CO) under normothermia, while the desired mean arterial pressure (MAP) varies between 60 and 70 mmHg (43.9%) and between 50 and 60 mmHg (41.5%), respectively. At body temperatures less than 18 degrees C CPB flow is reduced below the calculated CO (70%) while 27% of departments use normothermic flow rates. The preferred MAP under hypothermia is between 50 and 60 mmHg (59%). The results of intra-operative neuromonitoring are documented on the anesthesia record (77%). In 42.5% of the departments postoperative neurological function is estimated by the anesthesiologist. Continuing education sessions pertaining to neuromonitoring are organized on a regular basis in 32.5% of the departments and in 37.5% individual physicians are responsible for their own neuromonitoring education. CONCLUSION: The present survey data indicate that neuromonitoring and neuroprotective therapy during CPB is not standardized in cardiac anesthesiology departments in Germany. The systemic use of available methods to implement multimodal neuromonitoring would be desirable

Anästhesiologisches Management bei mediastinaler Raumforderung

The perioperative management of patients with mediastinal masses is a special clinical challenge in our field. Even though regional anaesthesia is normally the first choice, in some cases it is not feasible due to the method of operation. In these cases general anaesthesia is the second option but can lead to respiratory and haemodynamic decompensation due to tumor-associated compression syndrome (mediastinal mass syndrome). The appropriate treatment begins with the preoperative risk classification on the basis of clinical and radiological findings. In addition to anamnesis, chest radiograph, and CT, dynamical methods (e.g. pneumotachography and echocardiography) should be applied to verify possible intraoperative compression syndromes. The induction of general anaesthesia is to be realized in awake-fiberoptic intubation with introduction of the tube via nasal route while maintaining the spontaneous breathing of the patient. The anaesthesia continues with short effective agents applied inhalative or iv. If possible from the point of operation, agents of muscle relaxation are not to be applied. If the anaesthesia risk is classified as uncertain or unsafe, depending on the location of tumor compression (tracheobronchial tree, pulmonary artery, superior vena cava), alternative techniques of securing the respiratory tract (different tubes, rigid bronchoscope) and cardiopulmonary bypass with extracorporal oxygen supply are prepared. For patients with severe clinical symptoms and extensive mediastinal mass, the preoperative cannulation of femoral vessels is also recommended. In addition to fulfilling technical and personnel requirements, an interdisciplinary cooperation of participating fields is the most important prerequisite for the optimal treatment of patients.Das perioperative Management von Patienten mit mediastinaler Raumforderung ist eine besondere klinische Herausforderung für unser Fachgebiet. Zwar stellt die Regionalanästhesie, als Verfahren der ersten Wahl, eine sichere und einfache Technik dar, doch häufig ist sie operationsbedingt nicht realisierbar. Für diese Fälle verbleibt die Allgemeinanästhesie, deren Durchführung wegen tumorbedingter Kompressionssyndrome eine akute respiratorische und hämodynamische Dekompensation (Mediastinal-Mass-Syndrom) auslösen kann. Die adäquate Versorgung der Patienten beginnt mit der präoperativen Risikoklassifizierung anhand klinisch-radiologischer Befunde. Neben Anamnese, Röntgen und computertomographischer Untersuchung des Thorax, werden dynamische Verfahren, wie Pneumotachographie und Echokardiographie zur Verifizierung möglicher intraoperativer Verdrängungserscheinungen herangezogen. Die Narkoseleitung erfolgt wach-fiberoptisch, wobei der Patient unter Erhaltung der Spontanatmung intubiert wird. Die Anästhesie wird inhalativ oder intravenös mit kurzwirksamen Präparaten fortgeführt; Muskelrelaxantien werden, falls operationstechnisch möglich, nicht verwendet. Wurde die Anästhesie als „ungewiss“ oder „gefährlich“ charakterisiert, werden je nach Ort der tumorbedingten Kompression (tracheobronchial, pulmonalarteriell, caval) alternative Techniken der Atemwegssicherung (unterschiedliche Tuben, rigides Bronchoskop) bereitgestellt und extrakorporale Oxygenierungsverfahren (Herz-Lungen-Maschine, HLM) im Operationssaal vorbereitet. Bei schwerer klinischer Symptomatik und ausgedehntem Mediastinaltumor erfolgt zusätzlich die präoperative Kanülierung der Femoralisgefäße in Lokalanästhesie. Neben der Sicherstellung der technischen und personellen Voraussetzungen ist die interdisziplinäre Zusammenarbeit der beteiligten Fachabteilungen eine Grundvoraussetzung für die sichere Patientenversorgung