Praktische Anasthesie, Wiederbelebung und Intensivtherapie最新文献

In 31 patients with congenital or acquired heart disease, functional class III NYHAC, effects of Sulfentanil (R 30730)--a new analgetic--on hemodynamics, inotropic state and myocardial oxygen consumption have been investigated intraoperatively, during extracorporeal circulation and postoperatively. Results are compared to a fentanyl-group and control-group. There was almost no change in cardiac index and stroke index. In comparison to fentanyl (dose relation fentanyl: sulfentanil = 10:1) there was a more pronounced decrease in aterial pressure, left ventricular pressure, peak dp/dt and myocardial oxygen consumption (-20%) in the sulfentanil-group. In contrast to the fentanyl-group there was, however, no increase in total pulmonary resistance with sulfentanil.

The risks attendant on regional anaesthesia derive from the condition of the patient, the technique employed and the skill, or lack of skill, on the part of the anaesthetist. Patient-determined risk factors are: existent diseases and pathological conditions which in many cases cannot be rectified pre-operatively. The main difficulties and complications of regional anaesthesia arise from mechanical, pharmacodynamic and toxic factors and infection. Each technique carries its own specific risk. With due care many of the complications can be prevented.

Neurosurgery in the sitting position not only puts a strain on the cardiopulmonary system, but also carries the risk of venous air embolism. Special monitoring procedures as well as prophylactic measures greatly contribute towards the safety of the patient. The pathogenesis, pathophysiology and the symptoms of venous air embolism are reviewed, and various monitoring methods are discussed, with special reference to their reliability, sensitivity and practicability. The analysis shows that the Doppler ultrasound method, continuous capnography during the duration of the operation, intra-arterial measurement of blood pressure, recording of the central venous pressure and of electrocardiographic changes are essential means of routine monitoring. Suspected air embolism must be promptly dealt with not only by ligation of the severed vein but also by attempts at aspiration of the air bubbles via the atrial catheter. The latter, therefore, plays an important role both as a diagnostic parameter and a therapeutic agent. Although the suggested prophylactic measures do not absolutely protect against complications they will markedly reduce the incidence of venous air embolism.

The risk of aspiration pneumonia attendant on obstetric anaesthesia and the importance of the pH value of the aspirated gastric juice in the development of aspiration pneumonia are emphasized. The use of antacids and other agents as a preventive measure is reviewed.

The present case report describes a case of intrapleural infusion by means of a subclavian catheter. The clinical situation together with the signs of posteroinferior infarction in ECG led to a wrong diagnosis. During an emergency oepration the intrapleural infusion caused cardiac arrest which could be mastered by successful reanimation. After drainage of the intrapleural infusion the patient recovers without further complications. Prior to every infusion subclavicular catheters should be tested by blood aspiration.

A case of phrenic nerve paresis as a complication of puncture of the right subclavian vein in local anesthesia is reported. The paresis and phrenoparalysis disappeared after 90 minutes. Possible reasons are discussed.

The decision regarding fitness of a person to undergo surgery and anaesthesia is made by the surgeon and anaesthetist according to agreed criteria. The physician takes part in the decision only in those cases where additional information regarding the type and extent of the disorder is required or when doubtful findings need further clarification. Closer co-operation between anaesthetist and physician regarding the indications for pre-operative tests and investigations is desirable.

The narrow field of non-controversial indications concerning the application of digitalis glycosides is pointed out. Problems of routine digitalization of older patients not suffering from cardiac insuffiency are discussed with special regard to preparing them for operations. Up to now, from the viewpoint of anaesthesiologists no benefits of prophylactic digitalization have been found. In a retrospective computerized study, clinical hemodynamic parameters during introduction of anaesthesia have been investigated by means of anaesthetic data recorded during three years. Nondigitalized patients older than fifty years showed satisfactory cardiac functions, whereas prophylactically digitalized patients--compared with the control group--have been treated with plasma expanders earlier and at a double rate. Furthermore, higher heart frequencies and greater tendency to arrythmias were observed. Consequently, prophylactic digitalization cannot be recommended in general.

There is evidence of immunosuppressive influence of trauma/operation and anesthesia. The human immunological system is outlined as a complex functioning apparatus with humoral and cellular factors. The influence of operation and/or anesthesia on immunocompetence has been demonstrated by animal studies, in vitro examinations and clinical investigations. The analysis of these results and their significance for an impairment of the immunological surveillance of the patient is tried to be elucidated. There should be payed attention to the clinical consequences, especially in patients on high risk.

In 24 patients with congenital or acquired heart disease, functional class II--IV New York Heart Association Classification, effects of aminophylline on hemodynamics have been investigated intraoperatively, during extracorporeal circulation and postoperatively. Aminophylline caused a decrease in arterial pressure, left ventricular pressure, right and left atrial pressure, total systemic resistance and total pulmonary resistance. At the same time there was an increase in heart peak, peak dp/dt, cardiac index and stroke index. Our results demonstrate beneficial cardiac and extracardiac effects of aminophylline in man.