Bu Xiangmei Anesthesiology
From March to May 2018, I studied at the Anesthesiology department of Duisburg-Essen University Hospital, which not only broadened my horizon but also enriched my knowledge. I am very grateful to both Binzhou Medical University Hospital and Duisburg-Essen University Hospital for providing me with this opportunity.
1. Essen University Hospital
The Duisburg-Essen University was established on January 1st, 2003 by the University of Duisburg and Essen University. It is one of the top 10 universities in Germany in terms of enrollment. Essen University hospital is one of the largest general hospitals in Germany and it has 2,000 beds. It is famous for its cardiac center, neurosurgery and organ transplant centers. The hospital has a total of 31 operating rooms, which are distributed in different buildings according to different subspecialties. There are 3 operating rooms and 1 intervening operation room for cardiac surgery. More than 2,000 cardiac surgeries are performed annually, of which 1300 use cardiopulmonary bypass. About 20 lung transplantations and 3 heart transplantations are performed every year. They have more than 80 anesthesiologists.
They have the most advanced machines in the world, such as ECMO, TEE, high-frequency jet ventilators, and Da Vinci robots. Each operating room is equipped with Zeus anesthesia machine, Drager monitor, about 10 infusion pumps, heater, infusion heater (hotline), plasma heating device and surgical vision display (Anesthesiologist can see the operation, better for teamwork). In addition, ultrasound, defibrillators, nerve stimulators, TEE, blood gas analyzers, TEG testers, fiberoptic bronchoscope, video laryngoscopes, platelet function testers, and cells saver machines were distributed in corridors and pre-anesthetic rooms.
Of course, similar instruments are also available in many Chinese hospitals, but German instruments are more advanced and the details are almost perfect. For example, their transesophageal temperature monitoring probes not only take temperature but also connect stethoscopes. It is very convenient and the breath sound is very clear. The laryngoscope handle has a light so it can be used to see the pupil. The monitor has a composite aircraft, which avoids the trouble of changing various lead wires when transferring between pre-anesthetic room, operation room and recovery room. The first-aid kits can be found almost everywhere. There is a full range of rescue tools, including electric and manual bone marrow puncture needles in the kits.
2.2 Standardized management
The most obvious feature of the anesthesia department is its standardized management. This management method minimizes the deviation of the treatment effect due to different doctors. Each professional group has a leader, and the choice of anesthesia method is decided by the leader. For example, for general anesthesia, the standard procedure is as follows:
The standard procedure for nerve block is to use neurostimulation equipment combined with ultrasound for puncture and indwelling catheter for postoperative analgesia.
Anesthesia monitoring is very comprehensive. In addition to commonly used ECG, pulse oximetry, arterial blood pressure, central venous pressure, and temperature monitoring, they also monitor muscle relaxation as routine, tracheal catheter cuff pressure, pulse perfusion index (PI), and urine amount (hourly), blood gas analysis per hour, anesthetic gas monitoring (exhaled carbon dioxide, sevoflurane ,isoflurane, laughing gas concentration, and MAC value). TEE monitoring and Swan-Ganz catheters were placed on all cardiac surgeries to monitor cardiac output, heart index, and pulmonary artery pressure.
2.3. Work attitude
Strictness is the consistent style of the Germans, and German anesthesiologists are especially rigorous. Anesthesiologists never leave patients during the operation. If they have to go to the toilet or to drink water, they would ask somebody else to replace them. They are also very cautious when dosing. They strictly follow the various monitoring indicators. An abnormal situation must be identified. For example, when a patient undergoing transurethral resection with Da Vinci robots, airway bronchospasm occurred during surgery and was relieved after the drug applied. After surgery, the patient was not delivered to the ICU immediately. Instead, the bronchial tubes were examined with a bronchoscope to fully clear sputum and no abnormalities were confirmed before being sent to the ICU.
3.1Intracardiac electrocardiogram for the location of the central venous catheter
Method: A special central venous catheter was used to connect the ECG lead after puncture, instead of the ECG lead of the right upper limb. We will get a big P in electrocardiogram when the catheter is at the position of the right atrium. When the catheter goes back to the superior vena cava, the P wave returns to normal. This method can replace the X-rays examination, which is especially important for patients who need CVP monitoring.
3.2. Methods to prevent gas embolism in neurosurgery
Neurosurgery often uses sitting position. They are of high risk of air embolism because of its low venous pressure in the sitting position. The following measures are used to monitor the circulation of gas: first, Doppler is placed preoperatively in the precardiac area. If gas enters the circulation, significant noise is heard. Second, TEE monitoring is performed at the section of mid- esophageal aortic root short axis. Gas can be found in time to enter the right heart. Third, Swan-Ganz catheter is placed to monitor pulmonary artery pressure if the sudden increase in PA (pulmonary artery pressure) prompted gas into the pulmonary artery. In the sitting position, a large catheter is placed in the internal jugular vein in advance to the right atrium. Gas that goes into vein can be withdrawn through the catheter.
HIT（heparin induced thrombocytopenia） is divided into 2 types. Type I is relatively slight, and the incidence is 10%. With platelet 50x109/L or more, without thrombosis, it will gradually improve after the withdrawal of heparin. Type II is more severe and occurs within 5-10 days of the application of heparin. It may occur 1 day after use of Heparin if the patient had used heparin within 3 months. It is manifested as a significant drop in platelets, 1% of patients may have complications, and 0.3% of them will die. Clinical manifestations are arterial venous thrombosis (white thrombosis syndrome), thromboembolism, and bleeding tendency. It can be diagnosed by Heparin platelet aggregation test or Ellisa HIT-IgG antibody. The method of preventing HIT in the anesthesiology department of Essen University Hospital is to minimize the application of heparin. Heparin is not used during arteriovenous puncture and indwelling of the catheter. It is only washed with saline and flushed at a rate of 4 ml/h. No thrombosis is found. At present, heparin is widely used in China, and it is also recommended in critical medical textbooks. However, the risk of HIT is not mentioned.
There are 2 types of cardioplegia in extracorporeal arrest surgery at Essen University Hospital: one is cold crystalloid（HTK），the other is warm blood cardioplegia. The perfusion method is arterial warm blood 200-250mL/min, mixture of Potassium chloride and Magnesium sulfate f (4:1) 150mL/h for 4-5min.
3.5. Multimodal analgesia
According to different patients, surgical methods and pain, postoperative analgesic methods and drugs are not the same. For example, for patients who are going to the ICU after surgery, generally micro-pumps are used to give opioid analgesics or dexmedetomidine; patients with ventilators can also be inhaled with isoflurane to maintain analgesia at 0.8 MAC; patients with nerve block generally have an indwelling catheter attached to an analgesic pump; patients with a minor surgery can use a weak opioid analgesic drug in an anesthesia recovery room or ward; and pediatric ENT(ear nose and throat) surgery often involves anal ibuprofen when anesthesia is induced. When the surgery is finished, it is the time the drug takes effect. Analgesic methods are flexible and individualized.
4. Comparison between Chinese and Germany life
Germany’s economy is more developed than that of China, but life is far less convenient than ours. All shops are closed on Sunday, we can't pay by cellphone. There often have strikes. Germans keep history in mind. Museums can be found everywhere. A small city as it is, there are many museums in Essen, such as the History Museum, the Ruhr Museum, the Folkwang Museum of Fine Arts, the Red Dot Design Museum, the Soul of Africa Museum, etc. And even in the department of anesthesia at Essen University Hospital, there is a small museum which has several old days’ anesthesia machines.
Germans work rigorously, hate extra work, and know how to enjoy life. They are also very open. All equipment is allowed to take pictures. Foreign experts are often invited to give lectures. They often go to other places for exchanges. Doctor Peters, the chief director of this hospital, went to China to communicate before Easter and also had a travel to Hong Kong, Nanjing, Guilin and Shanghai. There are students from all over the world who are training. I have met students trained in Morocco and Mexico, as well as advanced doctors from Japan. The staff of their anesthesiology department is also of different skin color, one of them from Russia.
In addition, the most profound feeling is that our motherland is getting stronger and stronger. In Germany, we Chinese people are treated very warmly. More and more Germans can speak simple Chinese, and they often say “Hello, Thank you, goodbye” in Chinese. Whenever I ask for directions in the hospital, someone will help me enthusiastically. I am very grateful to Professor Peters and all the other anesthesiologists at Essen University Hospital for their help. I will try my best to put what I have learned in Germany to my work and provide a better service to my patients.