Die Anaesthesiologie最新文献

The term cardiopulmonary resuscitation-induced consciousness (CPRIC) describes the presence of "awareness" or "consciousness" during CPR, i.e. the at least partially conscious (co)experience of one's own resuscitation measures. Depending on the circumstances surrounding the resuscitation, including the medication administered, this may or may not be accompanied by a later memory of the event (= awareness of CPR). In the literature it is unanimously criticized that this is a little-noticed phenomenon and that there are as yet no generally accepted guidelines for dealing with it with or without medication. The problems of recognizing CPRIC based on the possible clinical signs and the importance for patients and personnel are presented. In addition, proposals for action, including analgosedative drug treatment, for the management of CPRIC both during and immediately after CPR are presented: intra-arrest or post-arrest sedation. The case report describes an out-of-hospital CPR with underlying pulseless electrical activity (PEA). During the resuscitation measures, the patient showed clinical signs of consciousness and was analgosedated while resuscitation was ongoing. Nevertheless, he was extubated without complications at the scene of the emergency approximately 5 min after regaining spontaneous circulation, increasingly conscious (Glasgow coma scale, GCS 14) and with stable vital signs.

Background: Patients who have survived a critical illness requiring intensive care treatment often suffer from persistent complaints, collectively referred to as post-intensive care syndrome (PICS). This syndrome includes both new and worsening symptoms that impair the quality of life and restrict activities of daily living and often hinder successful social and occupational reintegration. In addition to improving acute treatment, the transition from the intensive care unit (ICU) to standard care and long-term follow-up are rapidly becoming an important area of care improvement.

Objective: This review identifies and discusses relevant risk factors as well as preventive and therapeutic measures for the long-term care of critically ill patients. The focus is on the role of intensive care medicine in setting the course for optimal follow-up after critical illness.

Methods: Based on a systematic literature search, the results of previous studies are narratively synthesized to derive implications for the scientific and clinical practice.

Results and discussion: Up to 70% of critically ill patients experience relevant impairments during the first year after intensive care treatment. Besides optimization of acute treatment depending on individual needs, the systematic documentation and seamless communication of information regarding the intensive care course as well as close interdisciplinary collaboration are essential to minimize long-term complications. Intensive care medicine plays a key role in the care of critically ill patients even beyond ICU discharge by ensuring that, through sound decision-making and planning of the next steps during intensive care, short-term, medium-term and long-term goals can be achieved in a timely manner.

Background: Pulmonary hypertension (PH) is associated with a substantial increase in perioperative morbidity and mortality.

Objective: Perioperative management of pulmonary hypertension according to current data.

Material and methods: Analysis of the current literature, presentation and discussion of basic research and expert recommendations as well as presentation of two case reports.

Results: There is a lack of reliable and high-quality literature. A precise preoperative risk evaluation and individual treatment planning are mandatory for patients with PH.

Conclusion: Spinal anesthesia, thoracic epidural anesthesia or a combination of both can be an alternative to general anesthesia in patients with a high preoperative risk profile. A differentiated vasopressor and inotropic treatment is necessary to maintain physiological target parameters in PH. The early referral to a center with appropriate expertise is recommended in PH.

Background: Upper gastrointestinal motility disorders are common during anesthesia induction and are closely related to reflux aspiration; however, there is a lack of research on gastroesophageal reflux during anesthesia induction. In this study, we applied high-resolution impedance measurement (HRIM) to characterize gastroesophageal reflux during anesthesia induction.

Methods: A total of 28 patients participated in this study, with 14 patients receiving anesthesia induction with propofol and succinylcholine, and 14 patients receiving anesthesia induction with propofol and rocuronium. A HRIM catheter was used to collect esophageal impedance and pressure data throughout the anesthesia induction process.

Results: Prior to anesthesia induction, none of the 28 patients experienced gastroesophageal reflux. Within 10 min of anesthesia induction, 12 patients experienced gastroesophageal reflux (n = 12/28; 42.9%). A total of 16 reflux events occurred, all of which remained in the esophagus and did not enter the pharyngeal cavity. Within 5 min after anesthesia induction, 5 patients in the succinylcholine group experienced reflux (n = 5/14; 35.7%), with a statistically significant difference compared to before induction (95% confidence interval, CI 0.435-0.950, P = 0.02). While 4 patients in the rocuronium group experienced reflux (n = 4/14; 28.6%) within 5 min after anesthesia induction, with a statistically significant difference compared to before induction (95% CI 0.513-0.995, P = 0.049), there was no statistically significant difference between the two groups (95% CI 0.539-1.502, P = 0.500). Compared to baseline values, there was no significant decrease in barrier pressure (BrP) in both groups of patients during anesthesia induction. All 16 instances of gastroesophageal reflux during anesthesia induction were related to transient lower esophageal sphincter relaxation (TLESR).

Conclusion: Up to 42.9% of patients experienced reflux within 10 min of anesthesia induction, with the majority occurring within 5 min. The gastroesophageal reflux during anesthesia induction was related to TLESR, not to a decrease in gastroesophageal BrP.

Premedication is an essential part of anesthesiological work. On the one hand patients must be optimally prepared for the upcoming interventions and, if necessary, further pre-examinations must be arranged. On the other hand, however, patients must be informed in a legally correct manner about the risks of the upcoming anesthetic procedures. Deficiencies in risk information and documentation can lead to legal consequences. Therefore, this article intends to explain the legal basis of premedication and to provide practical guidance on which risks must be explained for which anesthetic procedures.

Lung separation for thoracic surgery is associated with varying degrees of difficulty depending on the age group. While the anatomical, physiological and technical requirements for the appropriate selection of bronchial blockers and double-lumen tubes in children > 12 years of age are comparable to those for adults, this is not the case for newborns and infants; however, at 13% they constitute the second largest group of children requiring lung surgery. Lung separation in this age group is technically demanding. The rate of cardiopulmonary complications is many times higher than in older children and adults. These procedures are therefore an anesthesiological challenge that should only be performed in specialized pediatric anesthesiology centers with appropriate personnel and structural facilities. In infants extubation should also be attempted on table to shorten the recovery time. This requires sufficient and multimodal pain therapy. The development of an internal enhanced recovery after surgery (ERAS) protocol can be helpful for high-quality perioperative treatment.

Background: To reliably assess fluid responsiveness using pulse pressure variation (PPV), tidal volumes (VT) of at least 8 ml/kg of ideal bodyweight are recommended. This contrasts with the current recommendations for lung-protective mechanical ventilation, which advocate VTs between 6 and 8 ml/kg to minimize ventilator-induced lung injury.

Objective: The aim of this study was to analyze whether indexing PPV to certain ventilatory parameters can be a possibility for VT-independent assessment of fluid responsiveness during mechanical ventilation with lower tidal volumes.

Material and methods: Hemodynamic and ventilatory data were collected from eight anesthetized, paralyzed, intubated and mechanically ventilated pigs. Each animal was ventilated with four different VTs (4, 6, 8, and 12 ml/kg) during volume-controlled ventilation, across four intravascular fluid states: normovolemia; hypovolemia induced by bleeding and two stages of fluid resuscitation induced by retransfusion and additional fluid administration. The PPV values were indexed to various ventilatory parameters including VT, plateau pressure (Pplat) and driving pressure (∆P), as well as transpulmonary pressures and composite parameters, such as minute ventilation (MV), mechanical power and mechanical energy.

Results: Indexing PPV to MV (PPV/MV) resulted in values with the smallest variation across different VTs, followed by PPV/VT, PPV/Pplat and PPV/∆P. These indexed parameters exhibited high ratios of explained variance (R²) to regression slope (β), indicating reduced VT dependency. In each case, higher values reflected a greater calculated fluid deficit.

Conclusion: Indexing PPV to MV can be a feasible way to use dynamic parameters of fluid responsiveness across a wide spectrum of ventilator settings, such as during lung protective ventilation strategies involving lower tidal volumes. Future studies should evaluate the performance of the indexed parameters in guiding fluid therapy in the clinical setting and define thresholds.

Before therapeutic communication, which not only serves to exchange information but also reinforces therapy and has a therapeutic effect in itself, ubiquitous nocebo effects based on learning and expectation as well as negative suggestions enhanced by a natural trance state in emergency situations must be eliminated. Treatment and medication can only be optimally effective through placebo effects, i.e. by announcement with an explanation of meaning. To avoid stressors, the 10 meaningful topics derived from the basic psychological needs must be addressed. To accompany patients during operations, dissociation to an inner safe place of well-being and the appropriate reinterpretation of sensory perceptions can be offered. According to recent evidence of perception even during unconsciousness, for example during general anesthesia, resuscitation or coma, communication should not be limited to awake patients. Hypnotic language directed at the unconscious is appropriate.