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ANESTHESIOLOGY PROCEDURE MANUAL
Pediatric NPO Directives. 2Adult NPO Directives . 2
PREANESTHETIC LABORATORY DIAGNOSTIC TESTING GUIDELINES . 3
DEPARTMENT RECOMMENDATIONS . 3ABNORMAL LABORATORY RESULTS . 3
NEURAXIAL BLOCKADE AND ANTICOAGULATION . 5Summary . 92007 Infective Endocarditis Prophylaxis AHA Guideline. 10NON-OBSTETRICAL SURGERY IN THE PREGNANT PATIENT. 13EPIDURAL BLOOD PATCH PROCEDURE AT GMH . 14Diabetic Guidelines. 15
Rapid Acting:. 15Short Acting. 16Intermediate Acting . 16Long Acting . 16
Thoracoabdominal Stents. 17Endovascular AAA Stents . 17
PERIOPERATIVE MANAGEMENT OF PATIENTS IN RESPIRATORY ISOLATION. 18
PREOP . 18INTRAOP . 18POSTOP. 18Child with new onset varicella (chickenpox): . 19Adult with disseminated (multidermatomal) shingles:. 19
PACEMAKER & AICD . 20ROUTINE PRE-OP HOLDING LINES. 21
2 LARGE BORE IVs AND ART LINE . 212 LARGE BORE IVs (one on a blood set), ART LINE, CENTRAL LINE, EPIDURAL. 212 LARGE BORE IVs AND ART LINE . 212 LARGE BORE IVs AND ART LINE (with quad transducer). 21
Guidelines for Hazardous Exposure . 22EPIDURAL STEROID PROTOCOL. 23
History. 23Efficacy . 23Technique. 23Additional Notes . 23Conclusions. 24
NEONATAL SPINAL. 25Guidelines for Outpatient versus 24 Hour Observation of Infants after Anesthesia . 26
Pediatric NPO Directives
Less than 6 months: a. Clear liquids – 2 hours prior to arrival in the hospital b. Formula – 4 hours prior to arrival to the hospital
6 months to 3 years:a. Clear liquids – 2 hours prior to arrival in the hospitalb. Solids – NPO after midnight
3 years and oldera. Clear liquids – 4 hours prior to arrival in the hospitalb. Solids – NPO after midnight
Adult NPO Directives
Clear liquids – 4 hours prior to procedurea. Solids – NPO after midnight
PREANESTHETIC LABORATORY DIAGNOSTIC TESTING
Preanesthetic laboratory and diagnostic testing is often essential; however, no routine* or diagnostic screening# test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g., age, pre-existing diseases, magnitude of the surgical procedure). The results of the tests relevant to anesthetic management should be reviewed prior to initiation of the anesthetic. Relevant abnormalities should be voted and action taken, if appropriate.
*Routine refers to a policy of performing a test or tests without regard to
clinical indication in an individual patient.
#Screening means efforts to detect disease in unselected populations of
The above adopted from ASA website.
1. Pregnancy Testing: Pre-op urine HCG’s are required within 7 days on all
female patients between 12-55 years unless the patient has had permanent sterilization.
2. EKG Testing: All patients (male and female) over the age of 50 years will be
required to have a pre-op EKG. For stable patients with low cardiac risk, an EKG within the last 6 months will be accepted. Clinical circumstances may demand that patients younger than 50 may need a pre-op EKG.
ABNORMAL LABORATORY RESULTS
Abnormal laboratory results are a constant in medicine. Responses to these can be inconsistent and confusing. In an effort to provide consistency and to hopefully improve patient safety, the Department of Anesthesiology has adopted the following guidelines. These have been adopted by a consensus committee of intra-departmental members, which have been based on a review of the available literature. It is understood that these recommendations can be somewhat
arbitrary. They are put forward to provide system wide consistency in an effort to improve efficiency and safety. They are subject to review and change as patient outcome data evolves.
Acceptable preoperative range for elective surgery, 3.0-5.5 meq.
in dialysis patients undergoing declot, 3.0-6.5 meq. in stable patients without
EKG changes consistent with hyperkalemia. For K+
greater than 6.5 consult
1. 130 meq. and above will proceed with surgery
2. 125-129 meq. – These cases will be done on a case by case basis, based on
the complexity of the surgery and chronicity of the hyponatremia.
3. 124 meq. and below – Elective surgery will be cancelled and the patient will be
sent for consultation and correction of the problem.
NEURAXIAL BLOCKADE AND ANTICOAGULATION
I. Neuraxial Blockade & Thrombolytic Therapy
Guidelines suggest avoiding fibrinolytic/thrombolytic agents for ten
days following puncture of non-compressible vessels.
Preoperative evaluation should determine whether fibrinolytic or
thrombolytic drugs should be used intraoperatively or postoperatively.
Patients receiving fibrinolytic and thrombolytic drugs should be
cautioned against receiving spinal or epidural anesthetic except in
highly unusual circumstances. Data are not available to clearly outline
the time that spinals and epidurals should be avoided.
In patients that have received neuraxial blocks at or near the time of fibrinolytic/thrombolytic therapy, neurologic monitoring should be instituted at an interval of not more than two hours. Also consideration should be given to using an infusion that will minimize neuromuscular blockade.
For patients with neuraxial catheters and having received
fibrinolytic/thrombolytic agents, there is no consensus on when the catheters should be pulled. Fibrinogen levels may be helpful.
II. Neuraxial Blockade & Unfractionated Heparin
For subcutaneous prophylaxis there is no contraindication to
neuraxial technique. After four days of heparin, it is suggested to obtain platelets.
Combining neuraxial technique with intraoperative
anticoagulation with heparin seems acceptable with the following cautions:
Heparin should be delayed one hour after needle
Remove the catheter 2-4 hours after the last
heparin dose and the patients coagulation status is
If needed after surgery, re-heparinization should be
delayed one hour after catheter removal.
Patients should receive neurological monitoring post-op.
If systemic anticoagulation therapy is begun with an
epidural catheter in place, it is recommended to delay
catheter removal for 2-4 hours following therapy
discontinuation and evaluation of coagulation status.
III. Neuraxial Blockade & Low Molecular Weight
Preoperative LMWH and neuraxial block. Peak
LMWH activity occurs about 2-4 hours after administration.
Needle placement should occur at least 10-12 hours
after the last LMWH dose when using routine once a
day dosing schedules. 2.
Patients receiving higher dosing schedules should
wait 24 hours before needle placement.
Postoperative LMWH and epidural catheter removal.
For once a day routine dosing of LMWH, the
catheter may be removed 12 hours after a dose.
Subsequent dosing should be delayed for 2 hours
after catheter removal. 2.
For twice a day dosing or higher LMWH dosing
epidural catheters should be avoided if possible.
Monitoring anti-Xa is not recommended.
Concomitant anticoagulant therapy with LMWH may
increase the risk of spinal hematoma.
The presence of blood during needle or catheter
placement does not necessitate postponement of
surgery, however initiation of LMWH should be
delayed for 24 postop.
IV. Neuraxial Blockade &
Warfarin should be stopped 4-5 days prior to a
scheduled procedure and a PT/INR obtained prior to
Other anticoagulants may complicate the picture.
For patients given warfarin prior to surgery, a PT/INR
should be done if the warfarin was given more than 24
hours prior to the central block or if two doses of
warfarin have been given.
An acceptable INR is less than 1.5 for central block or
epidural catheter removal. This value was derived
from studies correlating hemostasis with clotting factor
activity levels greater than 40%. Clinical circumstances
may force one to work outside of this limit, but at the
Neurologic testing of sensory and motor function
should be done routinely during epidural analgesia for
patients on warfarin therapy.
V. Neuraxial Blockade
& Antiplatelet Medications
History and Physical are better that testing in picking
NSAIDs alone do not create a level of risk that will
interfere with neuraxial technique.
For clopidogrel (plavix), the consensus is to wait 7 days
since the last dose.
For Platelet GP IIb/IIIa inhibitors:
Abciximab (Reopro)- Following administration
the time to normal platelet aggregation is 24-48
Eptifibatide (Integrilin)- Following administration
the time to normal platelet aggregation is 4-8 hours. 3.
Tirofiban (Aggrastat)- Following administration
the time to normal platelet aggregation is 4-8 hours.
VI. Neuraxial Blockade
& Herbal Medications
At this time there are no specific concerns as to the timing of neuraxial block in relationship to the dosing of herbal therapy, postoperative monitoring, or the timing of neuraxial catheter removal.
VII. Neuraxial Blockade
& New Anticoagulants
Hirudin Derivatives: Desirudin, lepirudin,
bivalirudin and Argatroban. There is presently no
statement regarding central block and these
Fondaparinux (Arixtra) produces its antithrombotic
effect through factor Xa inhibition. Neuraxial block
should occur only within clinical trials.
Despite this outline, a cookbook approach to the avoidance of spinal hematoma is inappropriate. The decision to perform neuraxial techniques and catheter removal in these patients rests on a risk/benefit analysis, on a case-by-case basis. Alternative anesthetic and analgesic techniques exist in patients considered to be unacceptable risks. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal hematoma. If you find yourself in uncharted waters, vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention. We must focus not only on the prevention of spinal hematoma, but also optimization of neurologic outcome.
Adopted from 2002 ASA Consensus Conference on Neuraxial Anesthesia and Anticoagulation
Key: 5+ = very acceptable risk; 4+ = acceptable risk; High, Very High and Danger = unacceptable risk.
2007 Infective Endocarditis Prophylaxis AHA Guideline
I. The need for infective endocarditis (IE) is based not only on the
risk of developing IE, but also on the severity of outcome if IE
were to occur. Highest risk patients include those with
Presence of a prosthetic heart valve2.
Unrepaired cyanotic congenital heart disease (including
Completely repaired congenital heart defects with prosthetic
material or device whether placed by surgery or by percutaneous catheter intervention, during the six months after the procedure
Repaired congenital heart disease with residual defects at
the site, or adjacent to the site, of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Previous cardiac transplantation with subsequent cardiac
valuvulopathy (substantial leaflet pathology and regurgitation)
*Highest risk patients no longer include:
1. Bicuspid aortic valve2. Acquired aortic or mitral valve disease3. Hypetrophic cardiomyopathy
II. Highest-risk patients who undergo dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa should receive antibiotic prophylaxis. Almost all dental procedures are included except:
1. Routine anesthetic injections through non-infected tissue2. Placement or adjustment of removable prosthetic or
3. Shedding of deciduous teeth4. Bleeding from trauma to the lips or oral mucosa
III. Highest-risk patients should receive IE prophylaxis for procedures involving biopsy or incision of the respiratory tract or mucosa (IE T&A). Prophylaxis for oral endotracheal intubation or routine bronchoscopy is not needed
IV. Antibiotic prophylaxis solely for the prevention of IE is no longer recommended for GU or GI procedures. In patients with routine infections, the appropriate antibiotic should cover IE concerns. If there is pre-existing infection from a drug resistant enterococcus then an infectious disease consult is suggested.
V. Highest-risk patients with infected skin or musculoskeletal structures should receive prophylactic antibiotics to prevent IE. The most likely organisms are staphylococci and betahemolytic strep and antibiotic regimens need to be effective against these organisms.
Table 1*Recommended Antibiotic Regimens (Single-dose 30-60 minutes before procedure)
Situation and Route
Unable to take
Allergic to penicillins
or ampicillin - oral
Allergic to penicillins
or ampicillin - unable
to take oral
* Adapted from reference 4**Weight-based dosing in adults not addressed in guidelines
NON-OBSTETRICAL SURGERY IN THE PREGNANT PATIENT
FROM THE DEPARTMENT OF ANESTHESIOLOGY CONSENSUS WITH THE
DEPT OF OB/GYN REPRESENTED BY DR. ROBERT CUMMINGS IN 2000
I. The obstetrician following the pregnancy should be made aware of the surgery if possible. Pre and post operative FHTs should be checked.
II. Unless there is an indication, the intraoperative monitoring of FHTs will not be routinely undertaken.
III. For routine intra-abdominal procedures, patients at eighteen weeks gestation or greater will be recovered in the OB PACU to monitor for the onset of premature labor.
IV. For peripheral procedures, patients at twenty-three weeks gestation or greater will be recovered in the OB PACU to monitor for the onset of premature labor or fetal compromise.
V. For complicated intra-abdominal, intra-thoracic, and intra-cranial procedures, patients at all gestational ages will be recovered in the 2nd floor PACU. OB PACU nurses may be brought to the 2nd floor PACU to assist in assessing for premature labor or fetal compromise.
VI. All unstable obstetrical patients from the main OR will be recovered in the 2ndfloor PACU.
EPIDURAL BLOOD PATCH PROCEDURE AT GMH
I. The ERD has primary responsibility for epidural blood patches Monday through Friday. On Saturday and Sunday this falls to the call personnel.
II. Monday through Friday the patient should go to outpatient reception on the second floor. The hospital has business office personnel there who can check the patient in.
III. For patients referred from the preceding day, every effort should be made to assess and provide a disposition for them ASAP.
IV. The referring physician (neurologist, neurosurgeon, etc) should fax a note to our office at 455-5743 outlining the present illness, concurrent medical conditions, and recent studies such as MRIs.
V. A present illness driven H&P as well as a procedure note should be written and placed on the patients chart prior to discharge as these patients sometimes return the following day.
VI. Remember that an epidural blood patch is considered a personally performed procedure and no other cases can be billed concurrently by the physician performing the procedure.
: Direct phone call from Neurologist to 455-3264 for consult.
I. If possible, patients with diabetes will be done as early cases. Since
this is seldom achieved, an attempt at reasonable blood sugar control should be made through preop management.
II. For patients on oral hypoglycemic agents:
1. Have the patient hold their am hypoglycemic agent on the day of surgery.
2. Check a blood sugar on arrival and make clinical adjustments based on this information.
III. For patients on insulin by injection or on insulin pumps, make an attempt to continue the patient’s basal insulin. Check a blood sugar on arrival and make clinical adjustments based on this information. Depending on the time of day, the patient may need the addition of substrate as IV glucose infusion or PO sucrose in water. Corrective insulin can be given as needed.
Insulin Aspart- onset<1/4 hr, peak 1-3 hr, duration 3-5 hr (Novolog)
Insulin Gluslisine- onset<1/2 hr, peak 0.5-1.5 hr, duration
Insuline Inhaled- onset 10-20 min, peak 2 hr, duration 6 hr (Exubera)
Insulin Lispr- onset<0.5 hr, peak 0.5-1.5 hr, duration <6 hr
Regular Insulin- onset 0.5 hr, peak 2-4 hr, duration 6-12 hr ( Humulin R, Novulin R)
Lente- onset 1-3 hr, peak 4-14 hr, duration 12-24 hr (Humulin L)
NPH- onset 1-2 hr, peak 6-16 hr, duration 10-24 hr (Humulin N, Novolin N)
Insulin Detemir- onset 1 hr, peak N/A, duration 6-23 hr (Levemir)
Insulin Glargine- onset 1 hr, peak N/A, duration 24 hr (Lantus)
Ultralente- onset 4-8 hr, peak 10-30 hr, duration 18-36 hr (Humulin U)
Humalog 75/25 Insulin Lispro/Insulin Lispro Protamine
NovoLog Mix 70/30 Aspart Protamine/Aspart
I. Place IV in preop in the rt. arm.
II. Place spinal drain in preop while patient is in the sitting position. If gross blood is obtained and you feel the catheter is in the proper position, leave the catheter in place and the case will be rescheduled for the following day with the expectation that the drain will clear.
IV. Place a MAC catheter in the rt. IJ.
V. Plan for general anesthesia with a single lumen ETT.
Endovascular AAA Stents
I. Two large IVs on rt. side if possible.
PERIOPERATIVE MANAGEMENT OF PATIENTS IN
1. Patient will be evaluated in Respiratory Isolation by the Anesthesia Department.
Use appropriate precaution while in the room.
2. Notify Infection Control Department (5-7177) of intent to bring the patient to the
3. Patient must be the last case of the day in that operating room.
4. Discuss with the floor nursing staff the details of the events on the date of service:
a. Patient must remain in Respiratory Isolation.
b. Patient must be transported with mask in place.
c. Transporters must wear masks and gloves.
d. Patient must be brought directly to the operating room. This is to occur
only after the operating room staff has acknowledged that they are ready
for the patient.
5. Patient may not
go to the common holding area preoperatively under any
6. If patient is in Respiratory Infection when assessed preoperatively, these guidelines
1. Leave the mask on the patient as much as possible.
2. Operating room personnel must wear respiratory protection at all times.
3. Mask must be back in place for transport to PACU.
4. All involved personnel should have positive antibody titer or history of exposure to
the patient’s current infection if possible.
1. Patient must be held in PACU in a private closed
room (negative pressure room is
2. Recovery room nurse must use respiratory precautions.
3. Minimize the number of recovery room staff to care for the patient.
4. Patient should be transported from PACU directly back to the respiratory isolation
room only after the floor is notified and related readiness to accept patient.
5. The room must be terminally cleaned after the case is completed including a wipe
down of all surfaces with appropriate antimicrobial agents.
Child with new onset varicella (chickenpox):
Very contagious until 6-8 days after initial outbreak or after all lesions are dry and
a) Non immune adultb) Immunocompromised adult
Adult with disseminated (multidermatomal) shingles:
Should not give shingles to adult with normal immune system or child with
May give shingles to immunocompromised adult
PACEMAKER & AICD
(Guidant Medical)Biotronik, Inc.
Cardiac Pacemakers, Inc.
(Medtronic, Inc.)ELA Medical
(Guidant Medical)Medtronic, Inc.
(St Jude Medical)Telectronics Pacing
(St Jude Medical)Ventritex
Companies in BOLD
ROUTINE PRE-OP HOLDING LINES
2 LARGE BORE IVs AND ART LINE
Big abdominal caseIntracranial Aneurysm CoilingCraniotomy (mini drip, NS for fluids)Carotid (1 IV to mini drip for vasoactive meds)Radical cystectomyFem Pop (possible epidural)Nephrectomy (possible epidural)Posterior Back Surgery (no IVs in hands)Prostatectomy (epidural for Dr. Dehart)Radical Neck (possible central line)Thoracotomy (epidural, a-line on non operative side)Thoracoscopy (call about possible epidural)Pectus Excavatum (probable epidural)
2 LARGE BORE IVs (one on a blood set), ART LINE, CENTRAL LINE,
WhippleLiver Resection (double transducer to monitor CVP)
2 LARGE BORE IVs AND ART LINE
Adrenalectomy (possible epidural, possible SG if for pheo)Endovascular AAA (consideration for lines on the rt side)Mediastinoscopy (call first, ? 2 IVs and a-line on rt side)Parathyroidectomy (1 IV)
2 LARGE BORE IVs AND ART LINE (with quad transducer)
AAA (Epidural PreOp) (SG placed in OR)Aorto Bifem (Epidural PreOp) (SG placed in OR)TAA (Spinal Drain PreOp) (SG placed in OR)
Guidelines for Hazardous Exposure
All blood and body fluid exposure should be reported immediately:
Immediately after first aid, reporting of an exposure (or possible exposure) to blood or body fluids is the responsibility of the individual who was exposed and is to be reported immediately to the Exposure Control Nurse (ECN) at the appropriate facility. In case of a Reverse Exposure (the patient is exposed to the
Healthcare worker), the HCW is again responsible for reporting immediately. See table 1 below.
GMMC (includes all of the 7:15 – 3:30 p.m.
Greenville Campus, Cross After hours on weekdays, Notify the Administrative Creek and Practices not
follow directions on the voice mail.
follow directions on the voice mail.
Nurse at 797-1069, and follow directions on
Notify the GMH Administrative Supervisor on beeper 996-0010.
For problems at any locations, call beeper number 290-3386
For any other Infection Control issues please call the main office of Infection Control at GMH at 455-7177. Your concern will be forwarded to the appropriate Infection Control Practitioner. If your need is of an immediate need and you do
not get to speak to someone in a timely fashion, please beep the Infection Control nurse on call on beeper 290-3386.
EPIDURAL STEROID PROTOCOL
Epidural steroids, either alone or in conjunction with local anesthetics, have been widely used for relief of back pain since 1960. Most early studies used large injectate volumes varying from 20 to 145 ml. and were composed of a number of local anesthetic/steroid combinations.
methylpredinsolone acetate (Depo-medrol) or triamcinalone diacetate (Aristocort) diluted in either saline or local anesthetics to deliver approximately 10 ml. or injectate volume.
Numerous studies have been performed with mixed methodologies and results. This divergence in results has led to the development of both staunch supporters and Burkian doubters. The studies demonstrating pain relief and improved work performance generally center on relatively acute radicular pain and evaluate patients between 1 week and 3 months. Less success is noted in long-standing chronic back pain and follow-up at 20 months and beyond. Repeat injections are generally recommended in patients who have partial relief after the first injection and the majority of practitioners will repeat the epidural injection even if the first appears ineffective.
After loss of resistance is obtained, a spinal test dose of local anesthetic is administered to insure against intrathecal injection, as most reported complications involve intrathecal injections. Then an appropriate dose of steroid (Depo-medrol 80-120 mg., triamcinolone 50-75 mg., Celestone soluspan 15-30 mg.) is mixed with a diluent and approximately 10 ml. is fractionally injected into the epidural space. The needle is then withdrawn and simultaneously flushed with a steroid-free solution to prevent a steroid “tract”. Some lower lumbar and sacral nerve compressions are better treated with caudal injections and require 25-30 ml. injections to guarantee adequate spread.
I personally believe in using 5 ml. of 0.25% bupivacaine to dilute the steroid for epidural injection. The local anesthetic can provide immediate relief from the inflamed nerve root, serves as a marker for an intrathecal injection, marks the spread of the solution in the epidural space, and can directly decrease pain due to
muscle spasm. Others use normal saline alone. Celestone soluspan contains two salts of betamethasone and does not contain either alcohol or glycol as a preservative. Rheumatology literature has some claims for betamethasone causing less post injection “flare” than other steroid preparations. Betamethasone is 5 times more potent an anti-inflammatory than either of the above alternatives, so 15-30 mg. appears to be an equivalent dose. Most centers space out repeat injections over 1-2 week intervals.
1. Epidural steroids have support in the literature for improved pain relief and function
2. Best results are obtained in acute pain syndromes with a definite nerve root
3. The topic of epidural steroids is well covered by Raj in Practical Management of
Pain and this text is being donated to the GAPA library.
4. A 1999 review published in Anesthesiology 1999: 91:1937-41 is included for
1. IV: Start IV prior to spinal or place IV after spinal has been placed in the
anesthetized foot and vasodilitation has begun. Remember as per published data from Linda Rice, MD that high spinals, significant hypotension, and bradycardia are almost unheard of in neonates.
2. Sedation: Avoid if possible.
Ketamine 2 mg/kg IM before spinal is placed if absolutely necessary.
3. Atropine 0.02 mg IM prior to spinal.
4. Drug Dosages: (May be prepared using an “epi wash”) Bupivicaine: 0.6-0.8 mg/kg Tetracaine: Prepare by placing 20 mg in 4 cc D10W (5 mg/cc). Dose is 0.8 mg/kg5. Use 1 ½ inch 22 ga pediatric spinal needle. After drug is administered flush with
Guidelines for Outpatient versus 24 Hour Observation of
Infants after Anesthesia
The purpose of these guidelines is to assist physicians caring for infants in
determining if admission to the hospital is required after an anesthetic. The admission, for one night of observation, is needed to monitor the infant for apnea and bradycardia (A&B) episodes,
which can occur up to 12 to 14 hours after an anesthetic. The
Department of Anesthesia would like to establish these minimal requirements to assist both surgeons and the parents of infants in planning for the perioperative period.
There will be two categories of infants under consideration: full-term and
premature. The standard definition of prematurity, which includes any infant born before 38 weeks post-conceptual age, should be used.
Any full-term infant younger than 46 weeks post-conceptual age at the time of
surgery should be admitted for A&B monitoring in the hospital for one night.
Any preterm infant younger than 50 weeks post-conceptual age at the time of
surgery should be admitted for A&B monitoring in the hospital for one night.
It should be noted that these are minimal guidelines and that individual
consideration of an infant may dictate a more conservative approach than dictated by these guidelines.
Erfahrungsbericht Hallo liebe Leserin Als erstes möchte ich dir sagen, dass du nicht alleine bist! Unzählige Frauen müssen einen schwierigen Weg zum Wunschkind gehen. Aus diesem Grund ist es mir wichtig, allen Betroffenen Mut zu machen, in dem ich hier meine Geschichte erzähle: Ich bin jetzt 32 Jahre alt und blicke auf 5 Jahren Kinderwunsch-Wartezeit zurück. Vorgeschichte Nach 2 Ja
Then those who were thrown out of the fancy planetary meetings should be let in again. Full transcription of the "last minute" addition to the Opening Session . 20:15 Guest speaker Ladies and Gentlemen, Let me first thank you for being present here tonight. I see a packed auditorium and, each time I pause, I hear a deafening silence emphasize your attention. Agreed, that