Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie最新文献

Trauma triggers complex physiological responses with primary and secondary effects vital to understanding and managing trauma impact. "Damage Control" (DC), a concept adapted from naval practices, refers to abbreviated initial surgical care focused on controlling bleeding and contamination, critical for the survival of severely compromised patients. This impacts anaesthesia procedures and intensive care. "Damage Control Resuscitation" (DCR) is an interdisciplinary approach aimed at reducing mortality in severely injured patients, despite potentially increasing morbidity and ICU duration. Current medical guidelines incorporate DC strategies.DC is most beneficial for patients with severe physiological injury, where surgical trauma ("second hit") poses greater risks than delayed treatment. Patient assessment for DC includes evaluating injury severity, physiological reserves, and anticipated surgical and treatment strain. Inadequate intervention can worsen trauma-induced complications like coagulopathy, acidosis, hypothermia, and hypocalcaemia.DCR focuses on rapidly restoring homeostasis with minimal additional burden. It includes rapid haemostasis, controlled permissive hypotension, early blood transfusion, haemostasis optimization, and temperature normalization, tailored to individual patient needs."Damage Control Surgery" (DCS) involves phases like rapid haemostasis, contamination control, temporary wound closure, intensive stabilization, planned reoperations, and final wound closure. Each phase is crucial for managing severely injured patients, balancing immediate life-saving procedures and preparing for subsequent surgeries.Intensive care post-DCS emphasizes stabilizing patients hemodynamically, metabolically, and coagulopathically while restoring normothermia. Decision-making in trauma care is complex, involving precise patient assessment, treatment prioritization, and team coordination. The potential of AI-based decision support systems is noted for their ability to analyse patient data in real-time, aiding in decision-making through evidence-based recommendations.

Neurotrauma results from violence on structures of the central or peripheral nervous system and is a clinically common disease entity with high relevance for patients' long-term outcome. The application of evidence-based diagnostic and therapeutic concepts aims to minimize secondary injury and thus to improve treatment outcome. This article describes the current management of the two main injury patterns of neurotrauma - traumatic brain and spinal cord injury.

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

Peak pressures ≥ 20 mbar are not a contraindication for laryngeal masks. The oropharyngeal leak pressure of a laryngeal mask does not correspond to the pressure at which oesophagogastric air leakage occurs. Setting a peak pressure limit of 20 cm H₂O on the respirator can lead to critical situations because the tidal volume may then remain too low. A good alternative is to use a pressure alarm limit. The use of laryngeal masks does not preclude the use of PEEP and/or relaxation.

Combining albumin dialysis for the removal of hydrophobic substances with classical haemodialysis in the treatment of acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) has a strong theoretical rational and clinical data showed a positive effect on laboratory and partly clinical characteristics of ALF and ACLF. However, neither the MARS nor the Prometheus System has so far been able to demonstrate a mortality benefit in ALF or ACLF patients. To date, only the use of therapeutic plasma exchange (TPE) has demonstrated significant removal of pathogen-associated (PAMPs), damage-associated molecular patterns (DAMPs) and pro-inflammatory cytokines. In addition, TPE also acts simultaneously by replacing protective but depleted mediators, thus improving multiple key pathophysiological principles of both ALF and ACLF. In ALF, both high-volume and standard-volume TPE showed a significant improvement in survival. The data on the use of TPE in ACLF is still sparse, with only two Chinese monocentric studies in patients with exclusively hepatitis B-associated ACLF suggesting potentially improved survival with TPE. The currently recruiting APACHE study will include patients with the modern EASL-CLIF definition of ACLF.

Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.

Clinics are, by definition, part of a country's critical infrastructure. In recent years, hospitals have increasingly become the target of cyber attacks, resulting in disruptions to their functionality lasting weeks to even months. According to the "National Strategy for the Protection of Critical Infrastructures (CRITIS Strategy)", clinics are legally obligated to take preventive measures against such incidents. This involves evaluating, defining, and developing failure concepts for IT-dependent processes within a clinic to be prepared for a cyber attack. Specifically tailored emergency plans for computer system failures should be created and maintained in all IT-dependent areas of a clinic.Additionally, paper-based alternative solutions, such as request forms for diagnostic or consultation services, department-specific emergency documents, and patient documentation charts, should be kept in a readily accessible location known to staff in the respective areas. The complete restoration of a clinic's network after a cyber attack often requires extensive recovery of numerous IT systems, which may take weeks to months in some cases.If the hospital has robust plans for cyber emergency preparedness, including regular scans and real-time backups, stabilization and a quicker resumption of operations may be possible.

After successful resuscitation, further treatment has a decisive influence regarding patient outcome. Not only overall survival, but also the neurological outcome that is crucial for patients' quality of life can be positively influenced by optimized post-cardiac arrest treatment. The management of various consequences of post-cardiac arrest syndrome is discussed in the current version of the ERC-guidelines in the chapter "post resuscitation care". A step-by-step approach based on an algorithm provides the necessary structure. The immediate treatment and stabilization of patients after ROSC is followed by the diagnosis of the triggering pathology in order to initiate adequate therapy. During the subsequent intensive care treatment, the focus is on optimizing neurological recovery.

In remote regions of Kenya, access to healthcare remains a persistent challenge, exacerbated by vast distances, rough terrain, and inadequate infrastructure. Amidst these obstacles, the AMREF Flying Doctors (AFD) based in Nairobi at Wilson Airport emerge embodying the spirit of medical outreach and innovation. Founded with the mission to provide timely medical assistance to underserved communities, this esteemed organization utilizes air transport to bridge the geographical barriers that often impede access to essential healthcare services.Since its inception, the Flying Doctors of Nairobi have played a pivotal role in delivering emergency medical care, conducting evacuations, and facilitating medical outreach programs across Kenya, Africa and the world. Operating with precision and efficiency, their fleet of aircraft is able to respond to emergencies, delivering medical teams and supplies to remote areas with the necessary celerity and exactness.Providing timely medical assistance, emergency evacuations, and specialized care to areas inaccessible by conventional means the service operates through a network of dedicated medical professionals, aviation experts, and technological infrastructure, ensuring rapid response and efficient delivery of medical services.This article follows a volunteer doctor and the author on the exciting journey to the Flying Doctors of Africa, based at Wilson Airport/Nairobi who reach out to a patient in medical needs from a rural airstrip within the Maasai Mara on which wild animals roam to medical evacuations which can span the entire globe.