Anaesthesiologie und Reanimation最新文献

We compared a new bellows ventilator (Kendall Cardiovent) with two other bellows (Dräger Resutator 63, Tagg Breathsaver) and seven bag or ball ventilators (Aerodyne Hope, Ambu Mark 3, Ambu Silicon, Dräger Resutator 2000, Laerdal Resu, Mercury CPR, Weinmann Combibag). Tidal volumes were measured with two Laerdal Recording Resusci Annies, one lying on the floor, one in a bed. Twelve participants performed mask ventilation with all ten devices on both manikins for two minutes, trying to achieve tidal volumes of between 0.8 and 1.21 as recommended by the AHA. The last ten ventilations each on the graphic strips were analysed for volume. The participants scored handling of the devices on a 6-point scale (1 = very good, 6 = insufficient). The results of the Cardiovent were compared to those of the other devices by rank sum test (percentage of correct ventilations) and sign test (subjective handling). The Cardiovent provided exact ventilation with 95% of ventilations) on the floor and 78% of ventilations in bed in the recommended range. However, the percentage of correct ventilations with the Cardiovent was not significantly different to the other devices except for a lower percentage of correct ventilations with the Combibag in the in bed setting. Concerning subjective handling, the Cardiovent was significantly superior to several ball ventilators.

Low perfusion of the liver due to hypovolaemia and sepsis-induced pathological distribution of blood volume can lead to severe liver disturbances. Damage to the liver as shock organ is manifold and affects other functions. Increased serum levels of ammonia and zerebral symptoms with disturbances of neurotransmission are responsible for the development of encephalopathia. Based on a case report, the differential diagnosis of Leigh-Syndrome as a mitochondric encephalopathy with uniform morphologic form is discussed. Long lasting parenteral nutrition, sepsis, metabolic imbalance and disturbance of the electrolyte balance can influence the extent of the mitochondric encephalopathy.

The administration of fluconazole in the ICU setting in dosages of > or = 800 mg/day or > or = 10 mg/kg/day has been reported in about 400 patients with candidiasis of different localisation including candidemia, with a rapidly increasing incidence of serious candidal infections. In Germany, fluconazole is approved for therapy of life-threatening infections caused by Candida spp. and Cryptococcus neoformans in a dosage of up to 800 mg/day. Especially in non-neutropenic patients with life-threatening infections caused by Candida spp., Cryptococcus neoformans and Coccidioides immitis, the results of a limited number of dose-finding trials show dose-dependent response rates. These findings strongly advocate the application of high-dose fluconazole; their evaluation, however, still awaits final clarification. The good safety profile even for maximum dosages of up to 2000 mg/day and the linear, predictable pharmacokinetics up to 1600 mg/day indicate the excellent tolerability of fluconazole in the clinical situation, which justifies prospective, randomized clinical trials with treatment groups as homogeneous as possible for further evaluation of the optimum dosage and duration of treatment in the various types of candidal infection.

Since the beginning of this century, a few biopolymers have been used as basic materials for volume substitution. Aside from gelatin and dextran, modified starch (hydroxyethyl starch, HES) is currently the first-choice means. Due to special manufacturing processes, different hydroxyethyl starches are now available. They have several different characteristics and produce different clinical effects. These clinical properties depend on the average molecular weight and the distribution of molecular weight as well as on the degree and pattern of substitution. The duration of volume effect, one of the most important parameters for the effectiveness of a volume substitute, depends to a large degree on the substitution. Elimination of HES from serum is delayed by a high degree of substitution and a high C2/C6 ratio of the substitution pattern. The molecular parameters of HES also influence other effects, such as cumulation in various organs and hemostasis. Critical reading of current HES literature shows that many questions still have to be answered. At the same time ways and means of optimizing differential volume substitution therapy and hemodilution therapy are emerging.

The diagnostic value of endotracheal aspirates with quantitative assessment and bronchoalveolar lavage (BAL) was investigated in 104 mechanically ventilated patients in an anaesthesiologic/surgical intensive care unit. Patients were either considered as "pneumonia positive" (77 patients) according to clinical, radiological or laboratory criteria or "pneumonia negative" (27 patients). Using a threshold of 10(5) colony forming units (cfu) per ml for endotracheal aspirates and 10(4) cfu/ml for BAL-fluid, the results were similar for both techniques (sensitivity 74% and 77% respectively; specifity 63%). In our investigation, in 80% of the cases microbial growth was observed in either both or neither of the techniques. Therefore 20% of the patients had positive results in only one of the two diagnostic procedures. As a consequence of the presented study, quantitative assessment of endotracheal aspirates as a cost-effective, low-invasive and simple technique could be helpful in diagnosing nosocomial pneumonia in mechanically ventilated patients. Performance of BAL is indicated in patients with clinical signs of nosocomial pneumonia and negative results in endotracheal aspirates (< 10(5) cfu/ml). Nevertheless, diagnostic uncertainty will remain in about 15% of all cases, even when both techniques are applied. The primary use of invasive bronchoscopic techniques, such as BAL, in diagnosis of nosocomial pneumonia has to be considered critically.

In prehospital emergency medicine, physicians are repeatedly faced with the question of when cardiopulmonary resuscitation (CPR) efforts should be withheld or terminated since they are clearly futile. Here, futile means the goal of saving life cannot be achieved. Determining futility involves qualitative und quantitative aspects. Does the possibility of simply restoring circulatory function justify the decision to initiate resuscitation or must the prospect of a prolonged meaningful life exist? The question of futility arises for the entire life-saving team during resuscitation efforts, for example, after traumatic cardiopulmonary arrest, prolonged down time, collapses in chronically-sick nursing home residents or during transport to hospital when prehospital CPR failed to restore spontaneous circulation. Possible solutions to this problem lie in restricting the objective of resuscitation to achieving a physiological effect in an organ system, i.e. regaining the cardiac pumping function, and in taking into account the chance of long-term survival and quality of life of the patient. Basically speaking, general ethical principles must be adhered to and these include consideration of a patient's right to self-determination. In the prehospital setting, however, the emergency physician is usually confronted with an unknown and unconscious patient and has no information about his preferences. In general, the patient's will to live and his desire for every effort to be made to save him can be assumed, even when there is only a slight chance of survival. Thus, unilateral decisions by emergency physicians to withhold CPR are only justified in special cases when it is obvious that CPR and preservation of life would not be in the patient's interest. When in doubt, resuscitation attempts must be made. The futility of these efforts may emerge later in hospital, or information becomes available regarding the patient's will which justifies an end to therapy.

Intravascular absorption of large volumes of solution without electrolytes is a common problem in transurethral resection of the prostate. In the present study we compared two different methods of resection (TURP vs. Vaporization TURP; 20 patients in each group) regarding fluid absorption and loss of blood. In addition, we report on 60 patients who had Vapo-TURP. The operations were performed by different very experienced surgeons. In both groups, spinal anaesthesia and standard regimes of infusion were used. The amount of fluid absorbed was measured by the ethanol method (2 vol.% ethanol; Widmark-formula). Haemoglobin, haematocrit and electrolytes were determined at set times. Ten of the 20 patients in the TURP group showed blood-alcohol levels > 0.1%/1000. In the Vapo-TURP group, only five of 57 patients (three patients with perforation of the prostate capsula were excluded) showed positive levels of blood-alcohol (< 0.05%/1000; fluid absorption < 150 ml). The difference was statistically significant (p = 0.002). Sixty minutes after the beginning of the procedures, the values of haemoglobin and haematocrit were significantly lower in the TURP group (7.68 +/- 0.41 vs. 7.38 +/- 0.64 mmol/l and 0.36 +/- 0.02 vs. 0.34 +/- 0.03). Regarding absorption of fluid and bleeding, Vapo-TURP was superior. From the anaesthesiological point of view, Vapo-TURP should be the method of choice, especially for the elderly.

The aim of the study was to investigate the influence on coagulation and platelet function of two 6% medium molecular weight hydroxyethylstarch solutions (HES, MW 200,000, DS 0.5) made of potato (K) and corn (M) starch. Twenty patients undergoing elective vertebral disc surgery were randomly assigned to one of the groups. Haemoglobin, haematocrit, protein concentration, fibrinogen, antithrombin III, factor VIII:C, von-Willebrand-factor, prothrombin time, activated partial thromboplastin time and platelet maximum aggregation and maximum gradient of aggregation (inductors: ADP, epinephrine, collagen and ristocetin) were measured before infusion and 30, 240 minutes and one day after infusion. The reduction of the prothrombin time (Quick) and antithrombin III and the decrease in fibrinogen and protein concentration, haemoglobin and haematocrit were due to haemodilution. The prolongation of the activated partial thromboplastin time (38.3 s K-group and 38.0 s M-group) and the decrease in factor VIII:C (71% K-group and 84% M-group) and von-Willebrand-factor (72% K group and 79% M group) were similar in both groups within 30 minutes of infusion of 1,000 ml HES. There was no change in platelet function within the groups. The infusion of a medium molecular weight solution is an effective and cost-saving method in volume therapy. Despite the physicochemical differences of the two HES solutions, there were no clinically apparent effects on coagulation and platelet function. Both preparations of HES up to a volume of 1,000 ml can be used equally in the clinical setting.

Both desflurane and sevoflurane have a favourable blood/gas distribution coefficient. There is concern, however, that environmental contamination is higher when these agents are employed since they must be used in relatively high concentrations. Our study seeks to determine the degree of exposure of recovery room staff to trace amounts of these two agents. Two hundred and seven surgical patients were included in the study. The recovery room studied had a volume of 243 cubic metres. The hourly fresh air supply for this room was 1,845 cubic metres, which results in 7.6 air exchanges per hour without air return. Measurements of trace concentrations of the inhalational agents were taken for 12 days. Concentrations of these anaesthetics were assessed in the recovery room with a real-time infrared spectrometer every 90 seconds. Mean exposure to nitrous oxide in the recovery room was 11.5 +/- 3.97 ppm and to isoflurane 1.4 +/- 0.31 ppm. All measured values were below the standard German threshold values. Trace concentrations of desflurane were 2.8 +/- 0.84 ppm and of sevoflurane 3.2 +/- 0.62 ppm. We conclude that the exposure to the inhalational anaesthetics in the climatised recovery room was low. The threshold values of 100 ppm for nitrous oxide and 10 ppm for isoflurane recommended by German law were not exceeded. When the new volatile anaesthetics are used, exposure of recovery room staff to trace concentrations of these agents is higher, but the concentrations do not exceed the levels allowed applicable German health regulations.

Ketamine is still a relatively seldom-used anaesthetic because of its psychotomimetic and sympathomimetic side-effects and because ketamine anaesthesia is poorly controllable. At present, the enantiomer S-(+)-ketamine (Ketanest S) is clinically used. During its application, a twofold higher pharmacologic potency and a faster elimination can be expected than with the racemic-ketamine mixture. Particularly in paediatric anaesthesia, no practical experience could be gained with this new drug. Form the current standpoint, an overview is given of the possible applications of ketamine in children regarding premedication and early induction of ketamine anaesthesia in combination with midazolam because ketamine can be inserted through the nose or rectum and it can also be applied orally or intramuscularly. Ketamine widens the anaesthetist's possibilities of premedication considerably and thus a calm induction of anaesthesia with stabilized spontaneous ventilation becomes possible in children with difficult conditions for venous puncturing, in very anxious children and in those who are not able to accept the necessity of treatment. The use of ketamine for the performance of small operations, for analgosedation during diagnostic procedures, for induction of anaesthesia in children with unstable haemodynamic conditions and with cardiac defects connected with reduced lung perfusion and for analgosedation in intensive care, in particular in patients with obstructive ventilation disturbances and diseases which need a therapy with catecholamines, is discussed. To avoid complications, the children should be supervised constantly during the application of ketamine. It should be used only in low doses and any combination with centrally depressive-acting drugs--with the exception of midazolam--should be avoided. During analgosedation with ketamine and midazolam in intensive care, the anaesthetist must be aware of a cumulative effect in particular in those children with liver and kidney insufficiencies. Analgosedation with ketamine and propofol can be better controlled horizontally and therefore, this combination should be taken more into consideration in children with the exception of those with diseases of inflammatory and septic genesis.