Anaesthesiologie und Reanimation最新文献

It is generally believed that in hypertensive patients both beta adrenoreceptor antagonists and calcium channel blockers can be continued up to the day of surgery without provoking problems with cardiovascular stability intra- and postoperatively. The same, however, has not been definitively established for angiotension converting enzyme inhibitors (ACEIs). A patient who was taking the ACAI enalapril for hypertension underwent two similar operations--right total hip replacement and three years later left--both with spinal anaesthesia. In the initial case, she received her enalapril on the morning of surgery, while for the second procedure, enalapril was stopped 48 hours earlier. Hypotension occurred which required more than 5 times the dose of etilefrin to maintain suitable blood pressure during the first instance as compared to that when enalapril had been discontinued 48 hours earlier. Spinal anaesthesia in conjunction with an ACEI may result in severe hypotension as seen in this patient. In view of this, it is suggested that in contrast to other antihypertenisve drugs, ACEIs should be withdrawn well in advance of spinal anaesthesia.

Remifentanil is an esterase-metabolized ultra-short acting mu-agonist opioid with a rapid clearance. The aim of this study was to determine the efficacy of remifentanil infusion for the short-lasting, but painful, transvaginal puncture for oocyte retrieval. Eighty consenting adult women (ASA I and II) aged 30.5 +/- 5 years and with a body weight of 69.1 +/- 9.1 kg were enrolled in this prospective study. After an oral premedication with 7.5 mg midazolam, all patients received 3 l/min oxygen. Subsequently, the remifentanil infusion was started with a rate of 0.3 microg/kg/min. Remifenanil doses were adjusted as needed for painless puncture and sufficient oxygen saturation in steps of 0.05 microg/kg/min. Dosage requirements, blood pressure, heart rate, oxygen saturation (pulse oxymetry, SaO2) and the level of analgesia were recorded every 3 minutes. Follicular aspiration lasted 11.8 +/- 4.1 min and the time of remifentanil infusion was 18.7 +/- 4.6 min. Dosage requirements of remifentanil were 0.3 microg/kg/min in 48.7% of all patients, but 27.8% needed only 0.25 microg/kg/min and 16.6% needed only 0.2 microg/kg/min. However, 4.2% of patients needed 0.35 microg/kg/min and 2.7% of all cases needed 0.4 microg/kg/min. Vital parameters remained nearly unchanged. Oxygen saturation decreased significantly from 99.2 +/- 0.7% to 98.2 +/- 2.4% after 3 min and to 94.9 +/- 7.2% after 10 min. Nine women showed motoric reactions to puncture. In many cases, the infusion of remifentanil after premedication with midazolam provided a suitable and satisfying anaesthesia for oocyte retrieval. Some patients, however, showed motoric reactions to vaginal puncture, while in other cases significant and clinical relevant decreases in Hb-oxygen saturation occurred. Therefore, we no longer carry out remifentanil infusion for transvaginal oocyte retrieval. We now prefer a remifentanil infusion of 0.2 microg/kg/min and propofol (1 mg/kg initially with intermittent doses of 0.5 mg/kg) combined with assisted ventilation by mask.

With increasing drug abuse of cocaine, the chances are growing that an anaesthetist comes into contact with an acutely intoxicated patient or chronic cocaine user while on call or during his daily routine. In South America chewing coca leaves is daily practise, while in the industrialised world the drug is sniffed, smoked or injected intravenously. Clinically, cocaine is used topically in ENT and ophthalmology due to its local analgesic and strong vasoconstrictive properties. Cocaine has a similar effect on the CNS as amphetamines and produces euphoria and hallucinations. Cocaine acts indirectly on sympathetic stimulation, release of dopamine and inhibition of catecholamine metabolism. It is metabolised in the liver and by serum esterases. Intoxication with cocaine leads to respiratory depression, arrhythmias, ventricular fibrillation and death. If an emergency operation during acute cocaine intoxication is necessary, all sympathomimetic anaesthetic drugs must be avoided. A deep anaesthesia must be provided to reduce the risk of cardiovascular complications. In the literature, anaesthesia is regarded as safe for patients with chronic cocaine misuse after abstinence of 24 hours. This case report shows that, even without acute intoxication, severe cardiovascular problems are possible in patients with chronic cocaine abuse. Hence, we recommend a cocaine-free interval of at least one week before elective surgical procedures.

As a basis for quality assurance measures, we analysed over a period of three years all iatrogenic tracheobronchial injuries that had to be repaired operatively at a university hospital. Twelve patients were affected. In most of these cases, the injuries were the result of an intubation during resuscitation attempts prior to or after admission to hospital (6 patients; 4 of them died later). The ruptures of 5 patients were due to complications of a dilational tracheostomy (1 died). In one case the laceration occurred in the course of a reoperation after oesophagectomy (conservative treatment after dehiscence of the tracheal suture). The tracheobronchial ruptures (length: 2 to 8 cm) were located in the pars membranacea and had surgical repair through a thoracotomy on the right side. During the period of this investigation, 43,773 elective intubations were performed. No such serious tracheal injuries were observed. The cause of death in the patients with tracheal injuries was mainly the underlying disease (resuscitation after myocardial infarction; tracheostomy because of pulmonary failure in septic disorders); however, it is likely that the injuries or the surgical intervention played an additional role in the negative outcome of the patients. The conclusion is that this complication rate must be reduced by in-service training and alteration of the procedures.

Mitochondrial disorders encompass a group of syndromes produced by genetic defects that disrupt mitochondrial energy production. The impaired mitochondrial energy supply affects nearly all organs and tissues leading to a variable clinical presentation. The possible multisystem involvement complicates the management of anaesthesia and perioperative care. Exact knowledge of the path physiology of mitochondrial diseases may help to avoid perioperative anaesthesiological complications. This report describes the anaesthetic management of a patient with a mitochondrial disorder during combined pancreatic and renal transplantation, and discusses some of the anaesthetic implications of mitochondrial diseases. Due to the potential susceptibility of patients with mitochondrial diseases to malignant hyperthermia, anaesthesia was induced and maintained as total intravenous anaesthesia using propofol, alfentanil and cis-atracurium. In addition, the patient was treated intraoperatively with hydrocortisone (initial bolus of 50 mg followed by a continuous infusion of 4.8 mg/h) and insulin (continuous infusion of 2 IE/h) in order to manage the adrenocortical insufficiency as well as to treat the diabetes mellitus. Using this anaesthetic technique, satisfactory haemodynamic and metabolic conditions were achieved during surgery. The postoperative period, however, was marked by severe respiratory complications.

Due to the growing number of high-risk patients, the increasing proportion of geriatric patients and the expansion of surgical and invasive-diagnostic procedures, medical stuff in hospitals are confronted with a rising number of emergency situations. Nearly 50% are of cardio-circulatory origin and occur during surgical interventions or immediately afterwards. Another cause of life-threatening complications are side-effects of orally or intravenously administered agents, especially after treatment with antibiotics, anaesthetics, analgetics and sedatives. Due to a lack of emergency training and management in most hospitals, the survival rate after cardiopulmonary resuscitation in general wards lies between just two and 35%. Thus it seems necessary to perform special training in CPR procedures and emergency management at regular intervals for the entire medical stuff. In addition, a special infrastructure for giving sufficient treatment in emergencies has to be established (emergency team, emergency telephone number, intra-hospital emergency car). The second part of this review presents current diagnostic and therapeutic strategies for the most common emergency situations, e.g. anaphylaxis, myocardial infarction, pulmonary embolism, gastrointestinal bleeding, and heparin-induced thrombocytopenia (HIT).

Chronic alcohol abuse causes several distinct diseases of the central and peripheral nervous system. Widely known are the alcohol withdrawal syndrome, alcohol-induced epileptic seizures, alcoholic polyneuropathy and myopathy, and Wernicke's encephalopathy. Beside these complications, less common syndromes have been identified, including Marchiafava-Bignami syndrome, subacute encephalopathy with seizure activity (SESA syndrome), and tobacco alcohol amblyopia. These syndromes can be diagnosed by their characteristic features in cranial MRI or in EEG. Moreover, certain disorders in which alcohol abuse is only indirectly involved in the pathogenesis are more frequent in alcoholics than in nonalcoholics. In daily practice, it is important to differentiate these disorders when encountering patients with chronic alcohol abuse.

Delirium is mental dysfunctions occurring as impaired attentional and memory systems with disturbances of consciousness, affectivity, psychomotor activity and sleep patterns. Numerous factors and underlying diseases may be responsible for these non-specific symptoms. Therefore, a thorough evaluation of preadmission history and current clinical status, supplemented by laboratory and extended technical diagnostic procedures, are always required. If delirium occurs in connection with emergency admission to hospital, an organic disease can most regularly be found. Due to its rapid time of onset and minor side-effects, the intravenous injection of 2.0 g gamma-hydroxybutyric acid is preferred for sedation of extremely agitated patients. Neuroleptic drugs are indicated in psychiatric patients. A central anticholinergic syndrome in the early postoperative period causative of the symptoms of delirium may respond to intravenous injection of physostigmine. Most of the time, however, these acute disturbances of brain function are best treated by correction of homeostatic imbalances, restoration of cardiovascular and respiratory stability and alleviation of pain. Postoperative delirium occurring two or more days later is frequently due to respiratory distress, followed by sepsis, alcohol withdrawal and many other causes including heart failure, exsiccosis and side-effects of drugs. In intensive care patients, delirium may be caused, for example, by withdrawal (alcohol, opioids, benzodiazepines), the onset of sepsis (often venous catheter related), side-effects of drugs, problems of communication, sleep deprivation and others. Treatment should focus on finding the right approach. Personal care should be intensified and include help from family members. Most problems arise from agitated, non-cooperative patients. Treatment with clonidine, gamma-hydroxybutyric acid or neuroleptic drugs like perazin and haloperidol may be required to reduce agitation and the activation of sympathetic influence.

Over the last years several clinical studies have modified the guidelines for preoperative fasting to reduce the risk of pulmonary aspiration. In most western countries the following guidelines are accepted: for clear liquids 2 hours, breast feeding 4 hours, small meals and breast milk substitutes 6 hours, heavy meals 8 hours. Since preoperative smoking is acknowledged as a risk factor, it should be ceased in most clinics 6 hours before induction of anaesthesia, as well. Smoking, however, does not increase the risk of pulmonary aspiration, as is often maintained, but increases the risk of postoperative pulmonary complications. To reduce the risk of perioperative pulmonary complications, cessation of smoking is necessary 8 weeks before operation. Stopping smoking only a few days before operation and anaesthesia even tends to increase the risk of pulmonary complications. Regarding cardiac complications, cessation of smoking 12 hours before anaesthesia is sufficient to reduce the incidence of cardiac ischaemia.