Anaesthesiologie und Reanimation最新文献

Symptoms of an acute myocardial infarction are a common reason for calling the emergency physician. Pre-hospital mortality caused by cardiac infarction is constantly high. The main potential for decreasing infarction mortality lies in the pre-hospital period. The problems and prospects of treatment in the early period are described in the case of a 73-year-old patient with an acute anterior infarction. The diagnostic and therapeutic approach is shown and discussed in this concrete case, taking into consideration the guidelines for diagnostics and therapy of acute myocardial infarction in the pre-hospital period of the German Society for Cardiology. A particular focus is the management of pre-hospital thrombolysis, the preconditions, realization and risks of which are described. In this context, the experience and competence of the emergency physician is prerequisite for the exact diagnosis and therapy. Furthermore, the importance of a smooth transition from pre-hospital therapy to intensive care is emphasized.

The differential-diagnostic strategy and the order of precedence of most diverse radiologic diagnostic procedures are discussed based on a case of retroperitoneal bleeding. Apart from iatrogen-caused bleedings, the therapeutic anticoagulant therapy in the context of the patient's disease, haemodialysis or a rare, spontaneously-occurring retroperitoneal bleeding play a substantial role. In the order of precedence of radiologic diagnostic procedures for fast diagnosis of a retroperitoneal haematoma, the abdomen CT-scan is the preferred method.

The validity of continuous measurement of hepatic venous oxygen saturation using a fibreoptic technique was investigated and set in correlation with intermittent measurements of saturation in hepatic venous blood in patients undergoing elective partial liver resection (pLR). Eleven patients (4 m/7 f, average age: 62.6 +/- 11.6 years) were included in the study after approval by the Ethics Committee of the University of Leipzig. A fibre-optic heparinized flow-directed pulmonary catheter (5.5-F) was inserted through the right internal jugular vein into the hepatic vein after induction of balanced anaesthesia (isoflurane/alfentanil). The position of the tip of the catheter was verified by fluoroscopic guidance. The oxygen saturation in the hepatic vein measured by the fibre-optic method and by blood-gas analysis (ShvO2) was compared at nine defined measuring points after in-vivo calibration (baseline). The ShvO2 decreased nonsignificantly from 84.4 +/- 10.4% to 77.1 +/- 19.1% during occlusion of the vessels in the liver hilus (Pringle's manoeuvre). The ShvO2 measured by the fibre-optic method and by blood-gas analysis correlated well (r = 0.815, p < 0.001). The limitations of the method result from artefacts based on surgical manipulations in the portal region (compression of hepatic veins, luxation of the liver). These artefacts can be differentiated by analysis of the pressure curves in the hepatic vein. Nevertheless, fibreoptic hepatovenous oxymetry seems to be a feasible method for continuous monitoring of the ShvO2 under intraoperative conditions in patients undergoing partial liver resection. Ischaemic situations of the liver can be detected and treated early. Additional information can be obtained from analyses of parameters in the hepatovenous blood.

A tracheal tear requires fast and proper treatment. A 55-year-old man working in a sewage pipe slipped and hit his neck on the edge of a concrete ring. The patient showed the following symptoms: cervical bruising, neck emphysema and increasing dyspnea. After several unsuccessful attempts to intubate the patient, a necklace incision was made immediately at the scene, under the suspected diagnosis of a torn trachea. A finger was used to look for the lower tracheal stump lying in the mediastinum. The lower stump was then intubated. In the hospital, an end-to-end anastomosis of the trachea as well as tracheotomy were performed on the patient. Because of the fracture of the larynx, an endolaryngeal stent was used to stabilize the lumen. Due to an injury to both laryngeal nerves, the patient suffered from dysphagea, whispered speech and dyspnea on minimal exertion as long-term side-effects. A lateralization of the vocal cord was made eight months later. Because of the quick assessment of the situation and proper treatment of the patient at the site of the accident, the patient was able to survive the injury.

The importance of geriatric patients is growing with the increasing number of people over the age of 65 and with the higher percentage of surgical interventions. Multiple physiological changes in the cerebrovascular, cardiovascular, respiratory, renal and hepatic system, and pharmacological changes such as a reduction in hydrophilic distribution and metabolism cause increased drug sensitivity, a reduced elimination rate and prolonged duration of action. Pre-existing diseases correlate with an increased rate of complications such as hypoxia, hypothermia and cardiovascular, pulmonary, cerebral or renal complications, the highest incidence of which occurs on the first and between the third and fifth postoperative days. To reduce the incidence of these complications, a thorough pre-anaesthetic examination and optimization of the patient's condition is recommended. Hypovolaemia or too intense premedication should be avoided. In cardiac-risk patients, a beta-adrenergic blockade is necessary. Purely regional anaesthesiological techniques should be used as they reduce one-month mortality by a third and morbidity by up to 59%. For general anaesthesia, preoxygenation and careful titration of the drugs used help to achieve cardiovascular stability. Institutionalized postanaesthetic standards help to avoid an aggravation of the patient's condition due to shivering, hypothermia or postoperative pain.

Sneddon's syndrome is a rare combination of generalised livedo reticularis and cerebrovascular accidents. Its clinical presentation varies widely and its aetiology is still not known. 60 to 80% of patients are female. First symptoms of the syndrome are mostly repetitive cerebral strokes, but reduced perfusion of the skin, seen as blue or red-brown mottling, precedes the strokes. The vascular disease is generalised and often accompanied by arteriosclerosis, systemic arterial hypertension, valvular heart disease and the presence of antiphospholipid antibodies. The diagnostic procedures are complicated and have to exclude other autoimmunological diseases. Therapeutic options are anticoagulatory therapy with warfarin, ASS or heparin, reduction of endothelial proliferation with ACE-inhibitors, and improvement of microvascular perfusion with prostaglandine. The increased anaesthesiological risk with these patients is due to the acute risk of thromboembolism and ischaemic cerebral and cardiovascular insults. The anaesthetic management must provide stable perfusion pressures for cerebral and myocardial arteries and avoid increasing risk factors for thromboembolism such as increased blood viscosity or stasis due to improper positioning of the patient. The choice of anaesthetic drugs is dependent on good controllability for haemodynamic stability. The high risk of patients with Sneddon's syndrome justifies a more invasive haemodynamic monitoring and postoperative surveillance on an intensive care unit. This case report describes the anaesthesiological considerations for, and management of, a patient with Sneddon's syndrome who was admitted to hospital for vaginal hysterectomy.

Emergency medical services are an indispensable part of out-patient medical care. For this purpose, special qualifications are necessary and these are taught within the framework of a course entitled "Certificate for Emergency Medical Services". These courses are organized either as a block course, that is a one-week course, or as weekend courses in progression. These two types of courses are compared here. Three block courses with 546 participants and five weekend courses with 599 participants were examined. The practical examination took the form of four practice stages, with 95 people from the courses taking the examination. The examination focussed on certain areas such as ECG diagnostics in the case of cardiac arrest, early defibrillation, removing helmets, immobilizing a fractured tibia, respiration with emergency equipment, vein punctures and volume substitution. Of the doctors attending the courses, 59.7% were residents, 35.7% were senior house officers and 4.6% were specialists or general practitioners. Thirty-nine (or 41.1%) of those examined attended a block course and 56 (58.9%) weekend courses. In diagnosing cardiac arrest, those attending a block course were more reliable (92.3% diagnosed correctly, compared with 67.9% in the other group). Fifteen per cent from both groups were not able to correctly diagnose ventricular fibrillation from the ECG. Of the block course participants, 39.1% chose defibrillation with the correct energy, compared with 24.2% of those attending weekend courses. One out of two participants recognized a deliberate fault in the ECG equipment. Thirty-seven per cent of participants of the block course and 35.9% from the weekend courses failed to choose the right size splint for neck immobilization. Regarding respiration, 67.2% of participants of the block course group and 71.4% of the weekend course group carried out manual artificial respiration. When using respirator equipment, 90% from the block course and 72.2% of the other group noticed an increase in respiratory tract pressure. When giving artificial respiration to an infant, 51.9% of the weekend course group and 35.9% of the block course group used an unsuitable emergency respirator. When choosing a central puncture point most participants picked the external jugular vein and gave their own previous experience as the reason (block course 48.2%, others 52.1%). Accuracy regarding the volume requirements in the case of large-scale burns, as well as choosing the quantity (16.7% compared with 7.4%) and the correct solution (47.9% compared with 40.7%) was unsatisfactory. For these reasons, we strongly recommend intensifying training in block courses for the future qualification of doctors in emergency services. It would also be useful to conduct an oral exam at the end of the entire course, which could also entitle candidates to use this professional designation as one of their qualifications.

To appraise the clinical impact of combined spinal-epidural anaesthesia (CSE) in patients undergoing total extraperitoneal laparoscopic hernia repair (TEPP), we performed a prospective study in 40 patients. These patients were randomized to receive either CSE (n = 20) or a balanced general anaesthesia (BGA) with controlled ventilation (n = 20). The aim of the study was to determine the impact of the intraoperative gas insufflation on compensatory respiratory reactions during regional anaesthesia. Therefore, blood gas samples were drawn and additional parameters were assessed as follows: noninvasive haemodynamic, lactate and glucose levels, differential blood count, and the patients' level of comfort during the perioperative setting, which was determined by a questionnaire. In our study it was clarified that the respiratory compensation of extraperitoneal gas insufflation is not decreased by regional anaesthesia. The haemodynamic state of the patients was stabilized by early interventions. In addition--there was no evidence that the anaesthesia regime used had any influence on the so called stress-parameters. Most of the patients with regional anaesthesia showed severe agitation often accompanied by chest pain. Hence, regional anaesthesia is not recommended in this setting.

Myocardial ischaemia/reperfusion situations may occur during the perioperative period. The cardioprotective effects of anaesthetics have been known for a long time: volatile anaesthetics reduce the ischaemic cell damage and infarct development. Besides ischaemia, reperfusion itself can also lead to cellular damage, thereby further increasing the ischaemic injury (reperfusion injury). Inhalational anaesthetics offer specific protective effects against reperfusion injury in isolated hearts as well as in rabbit hearts in vivo. This protection does not depend on haemodynamic side-effects of the substances and is even present after protecting the heart against ischaemic damage using a cardioplegic solution. Short periods of ischaemia render the myocardium resistant to subsequent longer periods of ischaemia. This strongest endogenous protective mechanism against the consequences of an ischaemia is known as ischaemic preconditioning. The protective effect can also be produced by stimulation of different types of receptors: the respective agonists produce pharmacological (chemical) preconditioning. The common pathway of the signal transduction cascade of both ischaemic and chemical preconditioning includes the sarcolemnal and/or mitochondrial ATP-sensitive potassium channel. Volatile anaesthetics can imitate the protective effects of a short ischaemia, thereby producing chemical preconditioning. This effect depends, at least in part, on anaesthetic-induced opening of ATP-sensitive potassium channels.