Pathophysiologie des Kapnoperitoneums: Implikationen für Beatmung und Hämodynamik

[Fast-track Rehabilitation after Oesophagectomy]

The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.

[Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]

Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.

[Anesthesia for medical students : A brief guide to practical anesthesia in adults with a web-based video illustration]

In Germany, Austria and Switzerland, anesthesiologists are the second largest group of physicians in hospitals, but this does not correspond to the amount of anesthesiology teaching that medical students receive in medical schools. Accordingly, the chances of medical students recognizing anesthesiology as a promising personal professional career are smaller than in other disciplines with large teaching components. Subsequent difficulties to recruit anesthesiology residents are likely, although many reasons support anesthesiology as a professional career.Traditional strategies to teach medical students in anesthesiology in medical school consist of airway management or cardiopulmonary resuscitation attempts in manikins. Anesthesiology is a complex interaction consisting of anatomy, physiology, pharmacology, clinical evaluation, experience, knowledge, and manual skills. While some medical schools offer teaching in high fidelity simulators, clinical teaching in the operating room is often limited. When medical students opt for a clinical rotation in anesthesiology, there is a chance to demonstrate the fascinating world of anesthesiology, but this chance has to be utilized carefully by anesthesiologists, as young talents have to be discovered, supported, and challenged.We have put together a short guide for medical students for a clinical rotation in anesthesiology in adults in order to generate basic knowledge and interest in anesthesiology as well as a sense of achievement. Basic knowledge about premedication, induction, maintenance and strategies for anesthesia is discussed. Further, the most important anesthesia drugs are discussed and manual skills, such as intravenous cannulation, mask ventilation, intubation, and regional anesthesia are featured with QR-code based video illustrations on a smartphone or personal computer. We did not discuss possible local mannerism and special patient groups (e. g., children, special medical history), local guidelines, or standard operating procedures.Medical students can be inspired by anesthesiology when not simply told about the tools of the trade and strategies, but instead by gaining knowledge and clinical skills that render a sense of achievement, likely during a clinical rotation into anesthesiology. A short theoretical instruction of anesthesiology enables rapid and targeted orientation even before a clinical rotation. Whether this subsequently results in a higher recruiting chance is currently unknown.

Improved ventilation-perfusion matching with increasing abdominal pressure during CO(2) -pneumoperitoneum in pigs

BACKGROUND

CO(2) -pneumoperitoneum (PP) is performed at varying abdominal pressures. We studied in an animal preparation the effect of increasing abdominal pressures on gas exchange during PP.

METHODS

Eighteen anaesthetized pigs were studied. Three abdominal pressures (8, 12 and 16 mmHg) were randomly selected in each animal. In six pigs, single-photon emission computed tomography (SPECT) was used for the analysis of V/Q distributions; in another six pigs, multiple inert gas elimination technique (MIGET) was used for assessing V/Q matching. In further six pigs, computed tomography (CT) was performed for the analysis of regional aeration. MIGET, CT and central haemodynamics and pulmonary gas exchange were recorded during anaesthesia and after 60 min on each of the three abdominal pressures. SPECT was performed three times, corresponding to each PP level.

RESULTS

Atelectasis, as assessed by CT, increased during PP and in proportion to abdominal pressure [from 9 ± 2% (mean ± standard deviation) at 8 mmHg to 15 ± 2% at 16 mmHg, P<0.05]. SPECT during increasing abdominal CO(2) pressures showed a shift of blood flow towards better ventilated areas. V/Q analysis by MIGET showed no change in shunt during 8 mmHg PP (9 ± 1.9% compared with baseline 9 ± 1.2%) but a decrease during 12 mmHg PP (7 ± 0.9%, P<0.05) and 16 mmHg PP (5 ± 1%, P<0.01). PaO(2) increased from 39 ± 10 to 52 ± 9 kPa (baseline to 16 mmHg PP, P<0.01). Arterial carbon dioxide (PCO(2) ) increased during PP and increased further with increasing abdominal pressures.

CONCLUSION

With increasing abdominal pressure during PP perfusion was redistributed more than ventilation away from dorsal, collapsed lung regions. This resulted in a better V/Q match. A possible mechanism is enhanced hypoxic pulmonary vasoconstriction mediated by increasing PCO(2) .