Das präoperative „Rauchverbot“

[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.

[Postoperative wound infections. Pathophysiology, risk factors and preventive concepts]

Postoperative wound infections are the third most common type of nosocomial infection in German emergency hospitals after pneumonia and urinary infections. They are associated with increased morbidity and mortality, prolonged hospital stay and increased costs. The most important risk factors include the microbiological state of the skin surrounding the incision, delayed or premature prophylaxis with antibiotics, duration of surgery, emergency surgery, poorly controlled diabetes mellitus, malignant disease, smoking and advanced age. Anesthesiological measures to decrease the incidence of wound infections are maintaining normothermia, strict indications for allogenic blood transfusions and timely prophylaxis with antibiotics. Blood glucose concentrations should be kept in the range of 8.3-10 mmol/l (150-180 mg/dl) as lower values are associated with increased complications. Intraoperative and postoperative hyperoxia with 80% O(2) has not been shown to effectively decrease wound infections. The application of local anesthetics into the surgical wound in clinically relevant doses for postoperative analgesia does not impair wound healing.

Influence of non-ventilatory options on postoperative outcome

Perioperative patient handling should urgently be updated according to current evidence and, if none is available, at least according to physiological knowledge. To prevent pulmonary aspiration, preoperative fasting for 2 h (clear fluids) and 6 h (solid food) and abdication of 20 min for smoking is sufficient. Beta-blockage requires an indication. Bowel preparation should be abandoned and minimal invasive surgery as well as local and regional anaesthesia should be used where possible. Fluid therapy should be rational and requirement-adapted, and hypothermia, postoperative nausea and vomiting, unnecessary drains, tubes and catheters avoided. A multi-modal opioid-sparing pain therapy, sufficient oxygenation as well as early nutrition and mobilisation all play an important role for patient outcome. Recent studies have postulated that combining single-modality evidence-based care principles into a multi-modal effort to enhance postoperative recovery has improved patient outcome. Henrik Kehlet termed such a principle the 'fast-track concept', comprehending the entire perioperative phase starting with preoperative preparation, over atraumatic surgical and anaesthesiological techniques reducing the neuroendocrine stress response and also comprising the postoperative treatment. This strategy has been shown to positively influence organ function, homeostasis, morbidity, need for hospitalisation and convalescence and, therefore, to reduce costs. Despite these promising results, general implementation of evidence-based measures leaves a lot to be desired. Further development of surgical minimally invasive techniques and ongoing evaluation of procedure-specific strategies is urgently warranted.

[Postoperative pulmonary complications: prophylaxis after noncardiac surgery]

Postoperative pulmonary complications are a major problem after upper abdominal or thoracoabdominal surgery. They lead to a prolonged ICU stay as well as increased costs and are one of the main causes of early postoperative mortality. Even after uncomplicated operations, postoperative hypoxemia occurs in 30-50% of patients. Acute respiratory failure involves a disturbance in gas exchange. The mortality ranges from 10 to 60% according to the severity of respiratory failure. The most important complications are interstitial and alveolar pulmonary edema, atelectasis, postoperative pneumonia, hypoventilation, and aspiration. Preoperative optimization, postoperative prophylaxis according to a stepwise approach, and early mobilization decrease the rate of complications.