When anaesthesia was in its infancy, the purpose of preoperative fasting was to prevent nausea and vomiting. In these early days of anaesthesia, liquid fasting periods were kept short to avoid exhaustion. The later introduction of the 'nothing by mouth after midnight' rule aimed to prevent aspiration. For decades, no distinction was made between clear liquids and solids. However, as studies could not demonstrate a difference in gastric residual volume when consuming clear liquids within the last 2-4 hours versus fasting for over 4 hours, the guideline recommendation regarding clear liquids was reduced to 2 hours by the end of the last century. As solid food remains in the stomach for longer, fasting periods of 6-8 hours are required. These should be adapted according to the type of food and the characteristics of the patient. However, periods of liquid fasting often exceed the recommended 2 hours, with a median duration of 9-12 hours. This can lead to dehydration, insulin resistance, and postoperative complications. As clear liquids leave the stomach quickly, an international, multidisciplinary consensus statement recommends implementing institutional protocols to minimise preoperative fasting times for liquids. These protocols can either encourage patients to drink clear liquids up to 2 hours before anaesthesia is induced or allow for liberal liquid fasting times.

Despite guideline recommendations allowing clear fluids up to two hours before anaesthesia, prolonged preoperative fasting remains common. This article summarises current evidence and clinical practice regarding preoperative fluid intake and highlights implications for perioperative management based on selective literature review.Excessive fluid restriction promotes dehydration and is associated with increased risk of delirium, haemodynamic instability, and acute kidney injury; patient comfort (thirst, anxiety, PONV, pain) is also impaired. Consistent application of the two-hour rule or liberal strategies ("Sip til send") shortens fasting times, improves thirst and well-being, and is not associated with higher rates of regurgitation or aspiration in current evidence. Intravenous fluid boluses immediately before induction provide short-term stabilisation but do not replace early, preferably oral, rehydration. Vulnerable populations, including paediatric and geriatric patients, appear to benefit most.Preoperative fluid management should aim to reliably prevent dehydration through patient-centred, evidence-based, and pragmatic strategy. Emerging data suggest that liberal fluid intake regimens may better achieve these objectives than the currently endorsed two-hour restriction from the outdated 2011 ESAIC guideline. Further well-designed implementation studies and adequately powered randomised trials are warranted to confirm safety and effectiveness.

Recommendations regarding preoperative fasting have been an integral part of anaesthesiological practice for decades. In recent years, in addition to the traditional focus on reducing the risk of aspiration, the pathophysiological consequences of (excessively) long fasting periods have increasingly been taken into consideration. The aim is no longer exclusively to provide standardised recommendations that are applicable to as large a group of patients as possible, but to achieve implementation that results in short, realistic fasting periods for patients.It remains important to reliably identify patients who are at potentially increased risk of perioperative aspiration to individually adjust not only the immediate perioperative procedure but also the preoperative fasting periods. Patients with delayed gastric emptying play a significant role in this context. This can occur idiopathically but also in the context of comorbidities such as diabetes mellitus, Parkinson's disease, autoimmune diseases, diseases of the autonomic nervous system or connective tissue (e.g. scleroderma), infections of the gastrointestinal tract or after previous major surgery. In addition, numerous medications - including opioids, tricyclic antidepressants and GLP-1 receptor agonists in particular - can lead to significant delayed gastric emptying.Particularly vulnerable risk groups in connection with excessively long fasting periods are children, the very elderly and frail, pregnant women and women in labour. These groups must be protected from excessively long fasting periods because they have limited compensatory mechanisms.The following overview provides an update on preoperative fasting in children, older people and pregnant women and presents further risk constellations associated with delayed gastric emptying. It can be seen as a best practice recommendation for specific issues.

Septic shock is a life-threatening condition caused by a dysregulated immune response to an infection and can lead to tissue and organ damage and ultimately to death. Early recognition and elimination of tissue perfusion loss caused by sepsis are key elements in the treatment of patients with septic shock. Hemodynamic management is divided into four phases. 1) initial phase, 2) optimization, 3) stabilization, 4) de-escalation. Fluid therapy is widely accepted in the initial phase, but recent evidence challenges its universality, highlighting fluid overload risks and increased mortality, necessitating individualized treatment.Recent research has identified five distinct hemodynamic phenotypes in septic shock based on echocardiographic and clinical parameters:Phenotype 1: Well resuscitated: Patients exhibit normal cardiac output and venous oxygen saturation (ScvO) without signs of volume depletion or overload.Phenotype 2: Left ventricular systolic dysfunction: Characterized by low left ventricular ejection fraction (LVEF) and cardiac output, these patients require inotropic support rather than additional fluids.Phenotype 3: Hyperkinetic state: Marked by increased cardiac output and LVEF, these patients appear volume-responsive but do not benefit from further fluid administration.Phenotype 4: Right ventricular failure: Patients exhibit significant right ventricular dysfunction and increased right-to-left end-diastolic area ratio, making them particularly vulnerable to fluid overload.Phenotype 5: Still hypovolemic: Defined by low cardiac index and volume responsiveness, these patients benefit from additional fluid administration.These phenotypes provide a framework for precision medicine in septic shock, guiding fluid and vasopressor therapy. Tools such as passive leg raise (PLR) testing and echocardiographic monitoring are essential for assessing fluid responsiveness and optimizing treatment. Additionally, early norepinephrine administration enhances fluid efficiency, preventing unnecessary volume expansion.A patient-specific approach incorporating hemodynamic phenotyping can improve outcomes by balancing resuscitation needs with the risk of fluid overload, ultimately optimizing survival in septic shock.

The circadian system, also known as the internal clock, plays an essential role in regulating physiological processes that are adapted to the 24-hour day-night cycle. This system modulates sleep-wake cycles, hormone secretion, metabolism, immune and cognitive functions, among other processes. In anesthesiology, we use hypnotics to strongly influence consciousness, sleep architecture, and the nervous system. It is therefore assumed that anesthesia and sedation may also influence circadian rhythms, as patients often report sleep disturbances and other cognitive and emotional impairments after anesthesiological procedures and surgeries. This overview summarizes current findings on the effects of anesthesia on circadian rhythms and highlights possible mechanisms and clinical implications.

Circadian intensive care medicine is a new field of research that investigates the pathophysiological mechanisms and clinical impact of disrupted circadian rhythms on the course of disease in critically ill patients. Initial studies have demonstrated rhythm disturbances at the clinical, hormonal and molecular level. These disturbances are often characterized by a loss of rhythmicity, for example reflected in reduced fluctuations of blood pressure within a 24-hour cycle. The loss of such rhythmicity has been associated with increased mortality rates. Moreover, circadian dysrhythmia is linked to several severe complications, including delirium. This article presents concepts and interventions in circadian intensive care medicine that may represent a new therapeutic horizon for critically ill patients in the future.

The circadian rhythm regulates key biological processes such as sleep, hormone balance, and immune defence. Sleep disorders are particularly prevalent among patients with chronic or advanced diseases and are associated with significant physical and psychological consequences. They impair quality of life, increase morbidity, and negatively affect the immune system. Diagnosis involves a thorough medical and sleep-specific history, supplemented by sleep diaries and screening questionnaires. Polysomnography remains the gold standard, while wearables can provide useful indications but cannot fully replace comprehensive diagnostics. Treatment should primarily focus on non-pharmacological interventions and addressing underlying conditions, with medications used only as adjuncts. Chronic pain and sleep deprivation interact, worsening patient outcomes. In critically ill patients, especially in intensive care settings, sleep disorders are common and increase the risk of delirium and mortality. Light therapy and consideration of circadian rhythms in pain management may improve treatment outcomes. Overall, sleep disorders represent a central and often underestimated symptom in pain management and palliative care, necessitating targeted diagnostics and individualized therapy. This article summarizes the current findings in this field.

The decision to initiate extended intensive care in older patients is often challenging. The ethical principles of beneficence and non-maleficence, together with the patient's autonomous will, form the foundation of decision-making. Important prognostic factors include frailty, functional status, and comorbidities. If intensive care treatment is initiated, it should be started promptly, but with a clearly defined treatment goal and predefined limitations regarding interventions that should not be undertaken. If, during the course, the decision is made against curative intensive care, palliative care should be provided. In situations where the patient's wishes or prognosis are unclear and the likelihood of meaningful benefit is low, a time-limited trial of therapy with predefined evaluation criteria may be appropriate. In any case, interdisciplinary and interprofessional team discussions help to improve prognostic assessment. Based on this, patients and their relatives can engage in shared decision-making to weigh benefits against burdens and to reach an informed choice.

Disaster medicine faces complex challenges and will play an increasing role in the future. Disaster medicine is dominated by a phased imbalance of available and required resources. Various factors, such as a possible hazard for the rescue forces, inaccessible terrain or even destroyed infrastructure increase the complexity enormously. For casualties, this can mean a concentration of medical care on life-threatening conditions. The primary goal of emergency planning is to ensure standard or contingency care and to avoid crisis care.

Over the past 12 months, Germany has experienced a number of significant events that have led to mass casualty incidents. Major emergencies, natural disasters and hazardous situations, including terrorism and amok, are characterized by an unexpected and simultaneous occurrence of a large number of casualties. Hospitals are key elements in the management of a mass casualty incident. After the emergency care on site, the casualties must be quickly transferred to hospitals ready to receive them. In order to ensure structured patient treatment in such an exceptional situation, hospitals must develop, train and practice emergency plans. Essential elements of contingency plans are the setup of a command and control structure, definition of dedicated treatment areas, triage, staff deployment and the stocking of materials. In prolonged scenarios the sustainment of treatment capacity is vital. Strategic hospital command and control is in charge to manage such situations.

Hospitals play a major role in civil protection. Maintaining medical care in the event of major emergencies, disasters, crises and wars is an essential component in coping with such situations and forms an important pillar for increasing the resilience of a society. In order to meet these requirements, hospitals must not only be designated as critical infrastructure, they must also be treated and equipped as such in order to form the basis for a robust healthcare system. In addition to the essential organizational measures to increase the safety of hospitals, structural and non-structural components must be incorporated into the planning of hospitals. Just as fire protection and hygiene do not need to be discussed when planning new hospitals, this should also be required for all aspects of safety listed in this article.

Phantom pain (PP) is a neuropathic pain syndrome that occurs after limb amputation and is perceived in the absent body part. Its exact pathophysiology remains unclear but involves peripheral nerve lesions, central sensitization, and cortical reorganization. Psychological and social factors also play a significant role in its manifestation. Phantom pain after amputation shows wide variability, affecting up to 82% of patients within the first postoperative year, with lifetime prevalence exceeding 80%, and higher rates observed after proximal or major amputations (e.g., transfemoral). Symptoms are typically described as intermittent, burning, or electric-like pain, often accompanied by non-painful phantom sensations. Diagnosis requires thorough neurological evaluation, detailed pain documentation, and the exclusion of differential diagnoses. Preventive strategies include perioperative nerve blocks and adequate surgical soft tissue coverage. Effective treatment is based on a multimodal approach. Pharmacological options such as morphine and pregabalin have shown efficacy, while others like tramadol or gabapentin appear less effective. Non-pharmacological methods - including mirror therapy and transcutaneous electrical nerve stimulation (TENS) - can support pain relief. Psychological interventions, particularly trauma-focused therapy, may be beneficial, especially in patients with post-traumatic stress symptoms. For optimal management, an individualized treatment plan combining pharmacological, physical, and psychological strategies is recommended.

The single administration of 8 mg dexamethasone during surgery reduces postoperative nausea, pain and hospitalisation without increasing the risk of wound healing disorders. This application is also safe for patients with well-controlled diabetes mellitus and, although it leads to a slight increase in blood sugar, this usually remains clinically insignificant.

One-lung ventilation (OLV) is a crucial technique in thoracic surgery, enabling effective lung isolation for procedures such as lung resections, lung-transplant, and the management of unilateral pulmonary diseases. The development of double-lumen tubes (DLTs) in 1949 by Carlens revolutionized lung separation, providing controlled ventilation of one lung while the other is deflated. Frank Robertshaw's modifications in 1962 improved safety and usability, making DLTs the gold standard for OLV. Modern DLTs, available as left- and right-sided DLTs, vary in size and material, allowing individual selection based on patient anatomy and procedure. Correct placement, verified via bronchoscopy, ensures optimal ventilation and minimizes complications like hypoxemia or airway trauma. Recent advancements include video-assisted DLTs (e.g., VivaSight), integrating real-time imaging to simplify placement and reduce the need for additional bronchoscopy.Bronchial blockers (BBs) offer an alternative to DLTs, particularly for patients with difficult airways or pediatric patients. However, BBs require advanced expertise and may dislocate more frequently than DLTs.Effective management of intraoperative hypoxemia during OLV includes recruitment maneuvers, PEEP, CPAP, or in severe cases, extracorporeal membrane oxygenation (ECMO). A comprehensive understanding of airway anatomy, device options, and ventilation strategies is crucial to the safe and effective application of OLV.

Airway management is a fundamental skill for anesthesiologists, particularly in the context of anticipated difficult airways. In such scenarios, current guidelines advocate for intubation under preserved spontaneous breathing - commonly referred to as awake intubation - as this approach minimizes the risk of upper airway collapse and ensures continuous ventilation.Flexible endoscopic intubation (FOI) has long been regarded as the gold standard for awake intubation. However, videolaryngoscopy (VL) is now firmly established in routine airway management, owing to its higher first-pass success rate and the growing familiarity among clinicians. As a result, VL is increasingly being used as a practical alternative to FOI in awake intubation, gradually displacing the latter in many institutions.This development presents both opportunities and challenges. While VL often enhances patient comfort and safety - especially in the hands of experienced users - it has also contributed to a decline in FOI proficiency. This is particularly concerning in cases where FOI remains indispensable, such as in patients with significantly restricted mouth opening or tumors of the oral or pharyngeal cavity. In such situations, the loss of routine FOI experience may compromise clinical outcomes.Future research and guideline development must acknowledge this evolving dynamic and seek to strike a balance between clinical efficiency, patient safety, and the preservation of core airway management competencies.

Meralgia paraesthetica (MP) is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN), typically caused by compression at the level of the inguinal ligament. The syndrome presents with burning pain, paraesthesia, and hypaesthesia in the anterolateral thigh, without motor deficits. The LFCN, derived from the L2-L3 spinal nerves, is vulnerable to compression or traction due to its anatomical course under the inguinal ligament. MP may result from both traumatic (e.g., surgery, injury) and non-traumatic causes (e.g., obesity, pregnancy, tight clothing). In some cases, the etiology remains unknown. Diagnosis is primarily clinical and based on patient history and physical examination. Imaging techniques and electroneurography can support diagnostic confirmation in unclear cases. If symptoms extend beyond the typical LFCN territory, are bilateral, or are accompanied by motor or reflex abnormalities, differential diagnoses - including radiculopathy, involvement of adjacent nerves, or anatomical variations of the LFCN - should be considered. Initial treatment is conservative and includes patient education, avoidance of precipitating factors, pharmacological pain management (NSAIDs, opioids, co-analgesics), and physiotherapy. Diagnostic and therapeutic nerve blocks using local anesthetics can provide symptom relief and aid diagnosis. Non-invasive adjunct therapies such as transcutaneous electrical nerve stimulation (TENS), Botulinum toxin A injections, acupuncture, and kinesio taping may offer additional pain relief in selected patients. In refractory cases, minimally invasive procedures including radiofrequency therapy or surgical decompression of the LFCN may be considered.

On May 4, 2024, the 23rd Obstetric Anesthesia Symposium took place as an event of the scientific working group "Obstetric Anesthesia" of the German Society of Anesthesiology (DGAI). As in previous years, topics related to obstetric anesthesiological practice were presented by experienced speakers and intensively discussed with the participants. Among other things, personal "recipes" and recommendations for daily practice, various options for analgesia in the delivery room, patient blood management in the delivery room, alternatives to obstetric epidurals, management of post-puncture headaches, and analgesia after cesarean section were addressed.