Praktische Anasthesie, Wiederbelebung und Intensivtherapie最新文献

Inquests following death on the table present the expert with a number of problems: he has to assess not only the causal connection between therapeutic or surgical procedures and death of the patient, but also the part played by anaesthesia in the fatal outcome. A number of cases are reported and an attempt is made to provide some objective guide-lines for the expert.

In order to establish liability there must be a causal connection between an objectively erroneous action and the ensuing damage. Criminal negligence presupposes that failure on the part of the anaesthetist to exercise the necessary care, including neglect properly to choose and supervise his assistants, is responsible for the mishap. Since anaesthesia constitutes a trespass to a person's body the consent of the patient has to be obtained. Such consent is valid only if the patient has been apprised of the nature, significance and risks of the anaesthetic method to be used. The anaesthetist must inform the patient whether general or regional anaesthesia is planned. The extent to which such information must be supplied and proof that it has been given may present difficulties. A practical approach is to provide the patient with as much information as will enable him to ask relevant questions and then to decide whether or not he wants further explanations.

Improper anaesthetic practice is caused among other things, by technical failure of apparatuses used in anaesthesia. An attempt is made to classify the technical hazards involved in anaesthesia, especially with regard to symptomatology and causes, to enable rapid detection and correction of technical errors or breakdowns.

The muscle relaxant Imbretil was investigated in 10 patients for initiating anaesthesia and for a prolonged artificial ventilation. In 50% of the patients a rather quick and drastic rise of the serum potassium-level was found. A cardiac arrest occurred in one patient due to a hyperkalaemia but fortunately was reversible. Consequently we do not use Imbretil in our Hospital anymore. Today better and less dangerous drugs are available instead--Imbretil must be placed as an obsolete drug.

Catheterization of the superior vena cava via the internal jugular vein with the indirect technique is practically always successful. The occurence of a pneumothorax is extremely rare. The special advantages of the indirect technique are: small puncture trauma, quick placement of the catheter in the superior vena cava and non-occurrence of false position. Heart irritations or even heart perforations are avoided because of standard catheter length respectively graduated catheters.

Weaning a patient from the respirator should be started as early as possible. The right time when to stope artificial ventilation is determined by certain criteria. Pathological processes which might interfere with the weaning process should be corrected beforehand. Incipient septicaemia, peritonitis, circulatory instability and a marked postoperative or posttraumatic rise in intracranial pressure are extrapulmonary contraindications for weaning. Apart from conventional weaning, continuous positive airway pressure ventilation and intermittent mandatory ventilation are discussed.

For postoperative parenteral feeding fructose proved preferable to glucose and xylitol. Although the infusions were started pre-operatively sodium deficiency and a fall in serum osmolarity developed during the postoperative stage. Administration of potassium to normalize lowered serum potassium levels was needed only on the first and second postoperative day. Serum calcium levels fell during the 7-days' period of observation but remained within the limits of normal. If parenteral feeding is to be continued for longer periods determination of the phosphorus balance is advisable to avoid excessive depletion of the endogenous phosphorus stores. Estimations of urinary osmolarity and urine volume indicated that fluid uptake was adequate.

Controlled respiration should have a place not only in cases of hypoventilation but also in the treatment of comatose and hyperventilating persons. Hyperventilation is liable severely to interfere with the blood supply to the brain, and this disturbance, in conjunction with the primary disease responsible for the comatose condition, such as hyperglycaemia, diabetes or cerebral trauma, may be a contributing factor to the lethal outcome. Controlled respiration helps towards regulation of the cerebral circulation and of the acid-base balance and provides improved conditions for normalization of the disturbed metabolism and thus greatly improves the prognosis of these cases.

The important role of pressure-measurement for many diagnostic, surgical, critical care and biomedical research problems should not be underestimated. For high accurancy the good knowledge of the underlying physical and mathematical principles seems to be necessary. On the other hand many users need some quick and easy methods for units of pressure measurements testing and calibration of their pressure-measurements system. In this survey a small introduction to the units is followed by basic considerations about fluid-mechanics. Fourier-analysis and theory of transmission. (The influence of terms like "natural frequency", "damping" and "phase lag" are shown). After the description of the commonly used pressure-transducers some hints are given to check the systems even in small laboratories.

A case of recurrent collapse of one lung is reported. It developed within 90 minutes after reexpansion of a completely collapsed lung induced by pneumothorax. There was no demonstrable cause for the recurrence of the atelectasis. Treatment was by means of a bird respirator (ventilation via a mouthpiece) with respiratory resistance. Factors possibly responsible for the secondary atelectasis are discussed.