Anaesthesiologie und Reanimation最新文献

Paul Sudeck is not generally recognised as a pioneer in anaesthesia, although he is well known for the atrophy of bone named after him. However, he not only championed the use of ether as a safe anaesthetic agent, described a method of ether analgesia for outpatient surgery and devised an inhaler for its administration, but also reintroduced nitrous oxide into Germany and invented possibly the first circle carbon dioxide absorption system with an optional attachment for continuous positive pressure respiration useful for the performance of thoracotomies.

Compared to English-speaking countries, anaesthesiology in Germany developed into an independent field relatively late. German doctors were sent abroad to other European countries to learn modern anaesthetic techniques. At the beginning of the fifties, colleagues from East Germany had increasing problems to travel abroad. Otto Jüngling, who specialised in anaesthesiology in Vienna under Otto Mayrhofer, came with a work permit to the small town of Quedlinburg in the Harz mountains in November 1952. One year later, in September 1953, he went to Berlin to set up a new department of anaesthesiology at Friedrichshain Hospital. After recognition of his speciality by the Austrian General Medical Council in Linz, Otto Jüngling became the first specialist for anaesthesiology to practise in Berlin. Scientifically he worked on the development of new anaesthetics and anaesthetic machines. A transportable suction unit was one of his excellent ideas. Furthermore, he rendered outstanding services to the training of anaesthesists in Berlin. Otto Jüngling resigned in February 1959 due to unsatisfactory cooperation with public authorities and went back to Austria were he lives today as a pensioner.

The routine use of nitrous oxide as a component of the carrier gas has been unanimously called into question in recent surveys, in fact, its use is now recommended in indicated cases only. Whereas a lot of contraindications are listed in the surveys, precise definitions of justified indications are not given. In clinical routine practice, there are absolutely no problems in carrying out inhalational anaesthesia without nitrous oxide. The missing analgetic effect can be compensated for by moderately increasing the additively used amount of opioids, while the missing hypnotic effect can be achieved by raising the expired concentration of the inhalational anaesthetic by not more than 0.2-0.25 x MAC. Thus, when isoflurane is used, an expired concentration of 1.2 vol% is desired, in the case of sevoflurane of 2.2 vol% and with desflurane of 5.0 vol%. In addition, doing without nitrous oxide facilitates the performance of low flow anaesthetic techniques considerably. Since the patient only inhales oxygen and the volatile anaesthetic, the total gas uptake is reduced significantly. Washing out nitrogen is no longer necessary. This means that the initial phase of low flow anaesthesia, during which high fresh gas flows have to be used, can be kept short. Its duration is now determined by the wash-in of the volatile anaesthetic. Since there is no uptake of nitrous oxide, a considerably greater volume of gas is circulating within the breathing system, minimizing the possibility of accidental gas volume deficiency. Thus, if anaesthesia machines with highly gas-tight breathing systems are used, even the performance of non-quantitative closed system anaesthesia becomes possible in routine clinical practice. The carrier gas flow can be reduced to just that amount of oxygen which is really taken up by the patient. This oxygen volume can be roughly calculated by applying the Brody's formula. Using fresh gas flows as low as 0.25 l/min, however, will result in a significant decrease of the output of conventional vaporizers outside the circuit. Thus, it becomes nearly impossible to maintain an expired isoflurane concentration of 1.2 vol%. With respect to their pharmcokinetic properties, the newer low soluble volatile agents sevoflurane and desflurane are better suited for use with flows corresponding to the basal oxygen uptake. Our own clinical experience, gained in the last six months from a trial involving over 1,800 patients, shows that the increase in opioid consumption resulted in additional costs of about 0.25-0.50 DM per patient. The increased concentration of inhalational agents brought additional costs of 3.00 to 5.00 DM for a two-hour anaesthesia. On the other hand, doing without nitrous oxide saved 2.61 DM per one-hour anaesthesia, whereby our consumption of nitrous oxide is extremely low as minimal flow anaesthesia is performed consistently. Furthermore, these calculations disregard the cost of the technical maintenance fo the central gas piping sys

"Gut injury" and a corresponding impaired gut barrier function are thought to have a high impact on the development of multiple organ failure (MOF) in the critically ill. Mucosal lesions and increased intestinal permeability can provoke translocation of bacteria and endotoxins and initiate local and/or systemic immune-inflammatory response, bearing the risk of development of multiple organ failure. Enteral nutrition using the physiological pathway provides the intestinal mucosa with nutrients, which is thought to reduce bacterial translocation and septic complications. Considerable gastric reflux and delayed bowel motility are the principal problems of enteral nutrition. Therefore, in the early postoperative period at least a nasoduodenal or--jejunal feeding tube or feeding jejunostomy is required. The commonly used enteral formulas are well tolerated. So-called "immunonutrition" includes special formulas supplemented with immunemodulating substances like arginine, omega-3-fatty acids, ribonucleic acids and glutamine. Some beneficial effects of immune-enhancing diets have recently been reported for immune response, infectious complication rate, systemic inflammatory response syndrome (SIRS), multiple organ failure (MOF), antibiotic usage and length of hospital stay, especially in patients after trauma or surgery. However, the definite role is still unknown and indications have still to be defined. Enteral feeding should start with small volumes, the amount being gradually increased according to a patient's individual tolerance. Common problems are gastric reflux, diarrhoea and distension, but usage of a suitable formula, a gradual increase or reduction in the amount of enteral feeding and, additionally, parenteral nutrition can help to overcome such complications. Clinical examination of the enterally fed patient should be performed carefully. Standard nutritional monitoring of electrolytes, glucose, triglycerides, cholinesterase, albumin, differential blood count, urine-glucose and nitrogen retention to assess the catabolic state should be performed routinely. Although only little data from randomised trials are available, enteral nutrition has advantages and is cheaper than total parenteral nutrition. In the critically ill, the goal of enteral feeding is not coverage of total caloric requirements, but continuous administration of at least a small amount in order to prevent gut mucosa atrophy. Nutrition is an important aspect in critical care medicine, and enteral feeding should be attempted at least partially.

In this study we present a computer-assisted monitoring system ("Opserver") which allows a continuous registration of directly measured values: hear rate (HR), systolic, diastolic and mean arterial pressure (SAP, DAP, MAP): systolic, diastolic and mean pulmonary arterial pressure (PAPs, PAPd, PAPm), central venous pressure (CVP), mixed venous oxygen saturation (SvO2), pulse-oxymetrically measured oxygen saturation (SaO2), cardiac output (CO) and calculated haemodynamic parameters: cardiac index (CI), total peripheral vascular resistance (TPVR) and pulmonary vascular resistance (PVR). The basic principle of this on-line monitoring system is the registration of calculated parameters combining data of various devices by specially-developed software. The procedure is shown in several clinical examples. The advantages of this system are:--monitoring of critical haemodynamic responses in cardiac high-risk patients relating to induction and finishing of anaesthesia including in- and extubation, recovery from anaesthesia, operation and transport and--exact documentation of the data for the purpose of clinical studies. Based on continuous measurement, this monitoring system allows an optimum evaluation of cardiorespiratory acute incidents, thereby permitting a problem-oriented therapy in high-risk patients with vasoactive medication in the perioperative period and in the intensive care unit.

In a case report, a Tachmalcor intoxication with a dose of 18 mg/kg body weight is described. This dose caused a ventricular flutter in the patient which lasted for a total of 10 hours, despite intensive treatment. The treatment began approximately three hours after the intoxication and concentrated on therapy of the ventricular tachycardia. The use of Xylocitin 2%, defibrillation, glucagon and sodium chloride is recommended with such symptoms. Additionally, we used hemoperfusion for drug elimination. Despite the cardiac rhythm disorder of such duration, no neurological deficiencies were observed in the patient. Intoxications caused by these drugs in normal intensive therapies are extremely rare and for this reason treatment can often be very problematic. The following article reports on the successful therapy of one such patient.

For neurosurgical procedures, the association between insertion of the Mayfield skull clamp and haemodynamic changes is generally recognized. We investigated the protective effect of two local anaesthetic substances (lidocaine and bupivacaine) under the conditions of total intravenous anaesthesia (TIVA) with propofol and alfentanil. Forty-two patients undergoing an elective craniotomy (tumor resection) were included in the study and randomly divided into three groups. All patients were given a total intravenous anaesthesia with propofol and aflfentanil. After induction, the skin areas for the pin were infiltrated with 0.9% sodium chloride (n = 14, control group 1), 1% lidocain (n = 14, group 2) or 0.5% bupivacaine (n = 14, group 3). After an interval of 1 to 2 minutes the pins were inserted. The intra-arterial line was inserted before induction. The haemodynamic parameters heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and mean arterial pressure (MAP) were monitored continuously. The haemodynamic parameters were recorded at four set times: (1) after induction of anaesthesia, (2) at the onset of the local anaesthesia, (3) at the insertion of the pin-holder, (4) five minutes after insertion. Insertion of the pins led to a significant increase in HR, SAP, MAP and DAP in the control group. These haemodynamic changes can be reduced by local infiltration with lidocaine or bupivacaine. The effect of both substances was the same in our study. Our results suggest that a significant reduction of the haemodynamic effects caused by insertion of the Mayfield skull clamp can be achieved by the use of local anaesthesia. Total intravenous anaesthesia alone with propofol and alfentanil cannot protect against these haemodynamic stimuli.

Four decades of anaesthesiological development are a relatively short period in the 150 years of modern methods of pain relief. But looking at the very different development of this special field--now known as anaesthesiology--we see that precisely the last 40 years have brought enormous local, national and international progress in anaesthesiology. This is true of the content as well as the speed of development, organisation and reflection in society. In all this, the development in Germany differed from that in comparable neighbouring countries due to the special political conditions that existed. Seen from 40 years of professional experience--gained in the eastern part of Germany--the development of anaesthesiology is presented in four periods: 1958-1968: A common beginning and arbitrary division. 1968-1978: Separate developments during the "Cold War". 1978-1988: Change through rapprochement--the Bahr concept also in anaesthesiology? 1988-1998: Joint development after political change in 1989.

The surveys of Hansen et al. demonstrated the safe inactivation of tumor cells in salvaged blood by g-irradiation. This method opens up the possibility of extending the intraoperative autotransfusion to tumour surgery. A prospective survey at the University Hospital of Leipzig demonstrated the practicability of intraoperative autotransfusion with gamma-irradiation of salvaged blood at a hospital with a decentralized structure. A clinically-relevant reduction of quality of the blood product by gamma-irradiation with 50 Gray or by transport was not observed. Adherence to fixed working regulations ensures that gamma-irradiation is conducted correctly and the salvaged erythrocyte concentrate is available in an acceptable period of time.

In a collision with a motor-car, a pedestrian suffered multiple injuries and a blunt trauma to the thorax. Immediately after the accident, the patient was haemodynamically instable and needed resuscitation several times, without lasting success. The coroner's office found that cardiac tamponade from a ruptured right ventricle was the cause of death. The incidence of ventricular rupture due to blunt trauma in motor-car accidents is about 10 to 15%. Since definite treatment is not possible at the site of the accident, the patient must be taken immediately to a cardio-surgical hospital after initial stabilization. Unfortunately, preclinical diagnosis of ventricular rupture is difficult. In this context, the increasing availability in ambulances of a 12-channel ECG, a highly sensitive diagnostic tool, represents significant progress. Cases like the one described above should be discussed at mortality conferences of pathologists, coroners and emergency physicians to increase awareness of this problem. Only if the possibility of cardiac rupture is considered and ruled out early in cases of massive multiple injuries with haemodynamic instabilities, will decrease the apallingly high lethality figures.