Anaesthesiologie und Reanimation最新文献

In spite of numerous interactions between the gut and the entire organism, today's knowledge in this field is still limited. In intensive care patients, reduced gastrointestinal perfusion and motility result in sequestration of fluids and translocation of bacteria and endotoxins, and the immunological function of the gut is depressed. To prevent gastrointestinal organ failure, early restitution of enteral nutrition is a main goal in intensive care medicine. Thus, the influence of anaesthetics on gut function is of special importance in analgosedation of intensive care patients. Pharmacological data of common anaesthetics allow judgement of their global effects on the gut. Interactions with opioid receptors of the enteral nerve system and systemic effects on the vegetative nerve system are of special interest. The results of in vitro and clinical studies show profound negative effects of opiods on gastrointestinal motility. Piritramide seems to be excluded from this judgement, but further studies with equipotent analgetic doses, when compared with fentanyl, are necessary. Ketamine is an analgetic alternative without relevant negative effects on gastrointestinal motility. Among the sedative components of analgosedation, midazolam, gamma-hydroxy butyric acid and probably propofol are useful, whereas barbiturates seem to have negative effects. Epidural anaesthesia with local anaesthetics is of additional benefit.

High sub-pressure in high-vacuum suction bottles falls as the bottles fill up. Suction pumps with reservoir have a constant low suction level and decisive advantages. The question is: does the use of a suction pump before processing and retransfusion influence the quality of the erythrocytes? The randomized, controlled, prospective study presented here deals with drainage blood and washed autologous red blood cells (warbc) from 60 patients after hip endoprosthesis surgery. In a comparison between suction pump and redon bottle, the following parameters were studied: haematological-parameter (haemoglobin, haematocrit, erythrocyte count, leukocyte count, thrombocyte count, MCV, MCH, MCHC), vitality (osmotic fragility, 2,3-DPG) and haemolysis parameter (GOT, LDH, plasma haemoglobin, potassium). Control samples were taken immediately after operation: sample one from drainage blood before processing and sample two from warbc before retransfusion. There were no significant statistical differences between the groups. The osmotic fragility of the retransfused red blood cells was slightly above normal values, while the 2,3-DPG was normal. "Old" erythrocytes were haemolysed. The concentration of plasma haemoglobin was clearly above the normal range. In the "redon group" GOT and LDH were clearly increased. The quality of erythrocytes from suction pump reservoirs is not decisively impaired.

Both clonidine and sevoflurane are interesting drugs for anaesthesia in maxillo-facial surgery. The present study was performed to discover how far it is possible to combine the benefits of sevoflurane (fast modulation of depth of anaesthesia, rapid emergence and recovery) and clonidine (reduction of perioperative stress response, prophylaxis of postoperative shivering, analgetic, antiemetic and anaesthetic-saving effect) without compromising the pharmacokinetic of sevoflurane. Twenty-eight patients were included in the present double-blinded prospective study. These patients were randomly treated with an infusion of 4 micrograms kg-1 clonidine (group 1) or a placebo (group 2) preoperatively. For anaesthesia a standardized procedure with fentanyl, propofol, rocuronium, N2O/O2/sevoflurane and an antiemetic prophylaxis with DHB was performed. The depth of anaesthesia was controlled by using spectral edge frequency (target--SEF90 = 10 Hz). Perioperative stress response was assessed by noting the effects on haemodynamic parameters (MAP, heart rate), and emergence and recovery were assessed by using established standardized tests. We confirmed the anaesthetic-saving property of clonidine only for fentanyl (-20%). On the other hand, there was no difference in MAC-sevoflurane values between the groups in keeping a steady target--SEF90 (1.62 +/- 0.26 versus 1.65 +/- 0.24 vol.%). The time until emergence and recovery was not significantly different. Even the occurrence of PONV, the VAS level or the postoperative analgesic requirement did not differ in the two groups. However, the incidence of postoperative shivering was significantly higher in the placebo group. The stress response to intubation or extubation was lower in the clonidine group. The haemodynamic parameters in the clonidine group were intraoperatively always below the baseline, in some cases by more than 20%, making therapy for hypotension or bradycardia frequently necessary. Postoperatively, the majority of the patients showed similar changes in these parameters, but did not reach the 20% mark. Preoperative clonidine comedication seems to complicate the management of anaesthesia. On the other hand, it is beneficial during the early postoperative period (e.g. stability in haemodynamics, prophylaxis of shivering) without compromising emergence and recovery. Our results show that therapy with clonidine should be better placed at the end of anaesthesia.

In clinical routine, the laryngeal mask airway (LMA) has proved an alternative to both endotracheal intubation and mask ventilation. In a survey among North German emergency physicians, aspects such as doctors' acquaintance with the LMA, the degree of ist distribution, its use and its potential benefits under non-hospital emergency conditions were evaluated. Seventeen per cent (n = 162) of physicians responded to the questionnaire, 75% of them (n = 122) anaesthetists. Although 73% (n = 119) were familiar with the use of the LMA from clinical experience, and again 73% would welcome having LMA use and application as part of the training of non-academic members of ambulance teams, only 24% (n = 37) of the responding doctors have an LMA on their emergency ambulances and merely twelve (7.4%) physicians reported actually using the LMA, one of them unsuccessfully. Sixty-three per cent considered the LMA the first-choice alternative in an unexpected "can't-ventilate-can't-intubate" situation. Use of the LMA should be extended in emergency medicine especially as its application is relatively easy to learn in clinical routine.

During general anaesthesia, the endtidal CO2 pressure serves as an estimate of the arterial CO2 pressure to regulate the ventilator setting. Important arterial to end-tidal carbon dioxide tension differences (P(a-et)CO2) have been observed among patients undergoing procedures which have substantial impact on the ventilation-perfusion ratio (V/Q). Data on the P(a-et)CO2 for procedures in which the V/Q-ratio remains constant are lacking. Repeated measurements of P(a-et)CO2 in twelve patients with chronic obstructive lung disease (COLD) and nine pulmonary healthy patients undergoing jaw surgery were performed. The P(a-et)CO2 in the pulmonary healthy subjects (5.96 +/- 1.68 mmHg) was lower than in the COLD patients (9.05 +/- 3.49 mmHg) (p < 0.01). A clinically significant P(a-et)CO2 > or = 8 mmHg was observed in 52% of the measurements in patients with COLD compared with 11% in the pulmonary healthy subjects (p < 0.01). Both patient groups showed only minimal intraoperative changes of P(a-et)CO2. The deviation of all subsequent P(a-et)CO2 values from the initial P(a-et)CO2 was 2.17 +/- 1.52 mmHg in the pulmonary healthy patients and 2.02 +/- 1.49 mmHg in the patients with COLD (p = 0.76). Intraoperative changes of the P(a-et)CO2 are small during procedures with no major alterations of the V/Q ratio. For these procedures an initial measurement of the P(a-et)CO2 in patients with lung disease should be sufficient. In pulmonary healthy subjects the P(a-et)CO2 seems to be negligible.

Long-lasting and extended maxillofacial surgery with operating times of more than ten hours are now routinely performed with an acceptable risk for the patient. Careful preoperative evaluation of the patient and interdisciplinary planning are essential for successful surgery. The close proximity of the surgical field and the airways as well as a high incidence of difficult intubation in these patients require special attention from the anaesthesiologist. Other perioperative focuses of anaesthesiological concern in long-lasting maxillofacial surgery are positioning of the patient, intra- and postoperative airway management, intraoperative monitoring, thermoregulation, fluid replacement and transfusion therapy.

Over the last few decades, major biomedical developments have been taken place so that dying and death are nowadays more a matter of deliberate decision--a change that has profound ethical and legal implications. This progress has influenced medical decision-making generally and intensively, especially that of the surgeon and the anaesthesiologist. The representatives of these professions are often confronted with problems of life-sustaining therapy at the beginning and the end of life and of resuscitative measures. The surgeon and the anaesthesiologist have to accept the necessity of close partnership while maintaining a clear dividing-line between their responsibilities, but at the same time jointly doing their utmost for the good of the patient. Above all the physician has to give due consideration to the patient's will, but there are many and sometimes great variations in the individual situations of conscious or permanently unconscious patients. The highest courts in Germany have laid down that the principles of medical ethics must supplement the law.

Patients undergoing total hip replacement are given general anaesthesia or spinal anaesthesia. The aim of this study was to investigate the experiences of patients before, during and after general anaesthesia (68 patients) or spinal anaesthesia (77 patients). Our investigation revealed that with regard to complications (nausea and vomiting, headache and back pains), no differences between the two methods occurred. Between 25 and 30% of the patients in both groups had these complications, although there were differences between both groups regarding their concomitant diseases and medication. Patients with spinal anaesthesia had a three times higher incidence of cardiac concomitant diseases and received corresponding drugs more frequently. We found that the time of postoperative analgesia after spinal anaesthesia (210 minutes) was significantly longer than after general anaesthesia (90 minutes). The majority of the patients in both groups (approximately 90%) were satisfied with the chosen method of anaesthesia and with the postoperative pain therapy. These findings make it possible to conclude that with the exception of differences in the postoperative analgesia time, there are no differences between general anaesthesia and spinal anaesthesia regarding complications and satisfaction of the patients with both methods of anaesthesia.

The gut not only serves as a main target for the detrimental effects of stress during and after surgery, but may also promote the development of multiple organ failure after different types of severe shock. According to a current hypothesis, an impaired intestinal barrier function is associated with a decreased separation of intraluminal bacteria and toxins and systemic circulation, which may induce sepsis and multiple organ failure. Hypoperfusion during shock, reperfusion injury of the splanchnic mucosa, alterations of the micro-ecology of the gut and immunologic and hormonal disturbances are important underlying pathophysiological mechanisms. Various therapeutic concepts have been proposed such as improvement of splanchnic perfusion, nutritive and metabolic treatment by means of immunomodulating nutrients, parenteral substitution of glutamine, early onset of enteral nutrition, normalization of gut motility and selective decontamination of the gut. However, no clinical study to date could clearly demonstrate a key role of the gut in the pathogenesis of sepsis and multiple organ failure. Likewise, the efficacy of different prophylactic and therapeutic procedures remain to be studied. An aggressive treatment of shock and avoidance of microcirculatory disturbances are of principal importance for prophylaxis of multiple organ failure.

In the postoperative period after coronary artery bypass graft surgery, the physician's enhanced attention should be focused on the incidence of myocardial ischaemia. The increased stress in the awakening patient as well as the return of autonomous reflexes can be the cause of imbalances in myocardial oxygen supply and uptake. Therefore, a probable influence of the pharmacologic profile of the intraoperatively applied anaesthetics on the incidence of postoperative myocardial ischaemia is of importance for adapting therapy on ICU to minimize any ischaemic risk. After approval by the ethics committee, a prospective randomized study was performed in 40 male patients who underwent coronary artery bypass graft surgery. The aim of the study was to compare balanced anaesthetic techniques performed with fentanyl and halothane, isoflurane and enflurane, respectively, with total intravenous anaesthesia performed with fentanyl and midazolam. An index to classify detection of ischaemia into three categories (ischaemia, probable ischaemia, no ischaemia) was established, based on measurements of myocardial lactate extraction and ST-segment analysis. Simultaneously, measurements of haemodynamic parameters and serum concentrations of catecholamines and intraoperatively applied anaesthetics were taken. In 8% of all measurements (30% of all patients) ischaemia was detected in the observation period and in 37% of all measurements (72.5% of all patients) probable ischaemia was detected. No significant difference was found concerning the incidence of myocardial ischaemia between all groups. The results of this investigation indicate that the application of inhalational anaesthetics for maintaining anaesthesia in coronary artery bypass graft surgery does not increase the risk of postoperative myocardial ischaemia.