Anasthesie, Intensivtherapie, Notfallmedizin最新文献

Following liver transplantation, the effect of postoperative parenteral nutrition with MCT/LCT fatty emulsions on the recovery of RES function in the allograft was investigated in a randomised prospective study of three groups of patients (group I: 50 g MCT/LCT fats twice weekly, group II: 0.7 g/kg body weight per day MCT/LCT fats, group III: 1.5 g/kg body weight per day MCT/LCT fats). RES function was assessed using 99mTc-HSA-MM clearance. There were no statistically significant differences in the recovery of RES function after transplantation between the three groups. A negative effect on RES function as a result of the administration of MCT/LCT fats up to 1.5 g/kg body weight per day can therefore be excluded.

Infants who had been originally preterm are subject to a particularly high risk after surgical interventions involving anaesthesia, due to a tendency to experience disturbance of respiratory regulation. Of a total of 130 originally preterm infants who had to undergo anaesthesia for so-called minor surgery, respiratory anomalies were seen in 66%, 48%, 10% and 7% of the infants in the age groups of 40, 50, 60 and 80 weeks after conception, respectively. Therapeutic measures were necessary only in patients up to a post-conceptional age of 40 to 50 weeks, the respective incidences being 24% and 20%. To minimise the risk of postoperative early and late apnea in ex-preterm infants, the following measures are presented and discussed: elective surgical interventions should be postponed until after the 50th post-conceptional week; in individual cases, indication for perioperative theophylline/caffeine treatment can be made more precise by means of preoperative ECG-coupled impedance pneumography; all measures of preoperative preparation, choice of anaesthetics and of adjuvant drugs, as well as perioperative infusion therapy, must be taken in full consideration of all neonatal previous diseases; patients up to the 50th week after conception require intensive-care monitoring primary and post-anaesthesiologically for at least 24 hours. In all patients who were older than 50 week after conception, two hours of intensive-care monitoring in the so-called "recovery from anaesthesia room" followed by 12 hours of ECG and apnea monitoring proved sufficient; in ex-preterm infants, even minor surgery should be performed on an in-patient basis only, to ensure proper monitoring.

After intravenous administration of epinephrine, serum potassium level shows a typically biphasic course. The initial rise is followed by a persistent fall to a lower level than the starting-concentration. The initially observed hyperkalemia is supposed to be caused by a potassium release from hepatocytes, mediated by an alpha 1-adrenoreceptor stimulation. The subsequent hypokalemia seems to be caused by the beta 2-mimetic component of epinephrine effecting the uptake of this ion into striated muscle cells. There are numerous clinical reports of marked hypokalemia as a consequence of beta 2-mimetic therapy. The additive effect of elevated endogenous catecholamines with the therapeutically applied epinephrine during cardiopulmonary resuscitation may be the cause of the elevated potassium levels often observed under these conditions. On the other hand, low serum potassium levels were measured in patients after successful resuscitation, as well as in patients with multiple trauma and with severe head injury. Moreover, hypokalemia seems to be a frequent event in the acute phase of myocardial infarction. A catecholamine-induced potassium shift into the cell is considered to be the cause of this decrease. The question whether in the case of myocardial infarction the hypokalemia is in itself arrhythmogenic as yet is not resolved. Because of the present knowledge about the influence of catecholamines on potassium metabolism it seems advisable to monitor potassium levels regularly during the above situations.

The depth of the proximal part of a normal Macintosh blade was carved more shallow and the tip of the blade was made adjustable in its angle by means of a joint controlled by a screw-lock fixation via a small wire parallel to the blade. Clinical experience with this modified blade in 33 patients is reported. In 10 of 13 patients with severely reduced mouth opening less than or equal to 25 mm and 19 of 20 patients with a mouth opening greater than 25 mm, visibility during laryngoscopy with the modified blade was improved, compared to the normal Macintosh blade. The carved proximal part of the blade improves its maneuverability in a small mouth avoiding undue pressure on the incisors, the adjustable tip increases the blade's pressure on the base of the tongue lifting the epiglottis.

In the field of anaesthesiology, outcome studies are undertaken to investigate the influence of different anaesthetic techniques on the intra- and postoperative course of patients in special clinical situations. The design of these studies should follow high methodological standards. In the past, most studies were undertaken in patients during Caesarean section and in the treatment of hip fractures in the elderly. Up to now, results do not clearly indicate the use of certain techniques in concrete clinical situations. Decisions must be made in accordance with clinical aspects, individual experience and in cooperation with the patient and the surgeon.

The catabolism of high-energy phosphates (HEP) during long-term preservation of donor hearts was investigated in mongrel dogs. Hearts were explanted after being randomly assigned to one of the following groups. Group I: normothermic ischaemic arrest (n = 6), group II: hypothermic ischaemic arrest (n = 6), group III: cardioplegic arrest with NIH cardioplegia (n = 6) and group IV: cardioplegic arrest with UW solution (n = 6). After explantation all hearts were stored cold for 24 hours, achieving a myocardial temperature of 0,5 degrees C. HEP content (ATP and creatine phosphate) and catabolites were determined from serial left ventricular biopsies taken before explantation and during cold storage. A significant decrease of HEP content was found in all groups. In group I and II a significant decrease of HEP was found after one hour of cold storage. After 4 and 8 hours cold storage ATP content was significantly higher in group II. Cardioplegic arrest of dog hearts resulted in a significantly delay of HEP depletion. In group III a significant decrease of ATP was only seen after 12 hours and in group IV already after 6 hours of cold storage. Hearts preserved with the newly developed UW solution showed significantly lower ATP values after 10, 12 and 24 hours than NIH preserved hearts. It is concluded that UW solution is less advantageous than NIH solution in terms of HEP preservation.

In 40 adult patients suffering from severe ARDS stage III and IV (Morel) we examined the course of the extravascular lung water (EVLW) measured by the double indicator dilution method with 858 single measurements, during mechanical ventilation with PEEP, or extracorporeal CO2 elimination (ECCO2 R). No correlation could be found between EVLW and the values of alveolar arterial oxygen difference (AaDO2) and intrapulmonary right-left shunt (Qs/Qt) or haemodynamic values such as CVP, PCWP, mean pulmonary arterial pressure, or the 24 h fluid balance. It was, therefore, not possible to estimate a prognostic trend based on a single measurement of EVLW. However, the course EVLW was more appropriate to perceive the prognostic trend of ARDS because a rapid decrease of very high EVLW was correlated with a decrease of AaDO2 (r = 0.87); whereas lethal ARDS (fibrosis) was associated with moderately increased, unchanged EVLW. However, during the ECCO2-R treatment the repeated estimation of EVLW and AaDO2 is a useful tool to assess recovery because other parameters such as Qs/Qt and chest computer tomography during long-term bypass are very difficult or impossible to employ for this purpose. A change of EVLW with increasing PEEP level could not be found. The reproducibility of 858 EVLW values was excellent with a coefficient of variation of 4.9 +/- 3.5%.

During a 12-month period 45 long-term intubated patients were treated by topical application of non-absorbable antibiotics (tobramycin, polymyxin, amphotericin B) together with an initial short-term intravenous application of an antibiotic with only minimal activity against anaerobic intestinal flora. These patients were compared to 48 patients in the previous 12-month period who had only interventional antibiotic therapy in case of established infections. This selective decontamination of the digestive tract (SDD) reduced the colonisation of the respiratory tract, thus also decreasing incidence of nosocomial pneumonia. There were fewer urinary tract infections, while the incidence of wound infections and septicaemia was influenced to microorganism a lesser degree. The number of gram-negative isolated microorganism was reduced, leading to a shift towards gram-positive organisms, especially S. epidermidis. During the 12-month study period there was no change of antibiotic sensitivity of the isolated microorganisms. Although we encountered no problems associated with multiresistant pathogens, routine microbiological surveillance is strongly recommended to detect changes in antibiotic resistance at an early stage.

Since intraoperative awareness is not infrequently observed under balanced anaesthetic regimens employing benzodiazepines for suppression of consciousness, we studied the effect of intravenous induction of general anaesthesia using the benzodiazepines midazolam, diazepam and flunitrazepam on mid-latency auditory evoked potentials and auditory evoked neuronal 30-40 Hz oscillation. Following informed consent in 30 patients scheduled for minor gynaecological procedures, anaesthesia was induced with midazolam (0.2-0.3 mg/kg b.w. i.v., group I n = 10), diazepam (0.3-0,4 mg/kg b.w., i.v., group II n = 10) or flunitrazepam (0.03-0.04 mg/kg b.w., i.v., group III n = 10). Auditory evoked potentials were recorded before, during and after induction of general anaesthesia on vertex (positive) and mastoides on both sides (negative). Auditory clicks were presented binaurally at 70 dBnHL with a frequency of 9.3 Hz. Using the electrodiagnostic system Pathfinder I (Nicolet), 1000 successive stimuli were averaged over a 100 ms poststimulus period and analysed off-line. Latencies of the peak V, Na, Pa were measured. By means of Fast-Fourier transformation-analysis corresponding power spectra were calculated to analyse energy portions of the AEP frequency components. In the awake state AEP showed an oscillatory component between 20 and 100 ms poststimulus latency. Corresponding power spectra indicated a predominant 30-40 Hz frequency. After induction of general anaesthesia using midazolam, diazepam and flunitrazepam, there was no increase in latencies of the peaks V, Na, Pa, but only a small decrease in amplitudes Na/Pa without statistical significance. The auditory evoked mid-latency neuronal oscillation persisted under induction of general anaesthesia with midazolam, diazepam, flunitrazepam.(ABSTRACT TRUNCATED AT 250 WORDS)

In a 29-year-old polytraumatised motorbike driver, massive blood transfusion led to a decrease of the body temperature to 28.1 degrees C rectal on the second day after admission. We could rewarm the patient using only a Clinitron bed, although he had persisting blood loss due to an intravasal coagulopathy. This method has proven to be noninvasive, effective and without any side effects.