Anasthesie, Intensivtherapie, Notfallmedizin最新文献

During a period of one year, all patients above the age of 60 with surgical repair of fractured neck of femur were investigated in a prospectively randomized design. A follow-up study included a total number of 56 patients, 32 were allocated to halothane anaesthesia with intubation, 24 received spinal anaesthesia. In addition, 15 patients of the halothane group and 17 patients with spinal anaesthesia were investigated with regard to endocrine stress response. Total mortality was 12.5%, and different anaesthetic management had no influence on the postoperative course. During the operation, adrenaline and ADH increased in both groups. This increase was attenuated by spinal anaesthesia. Noradrenaline was markedly increased even before the operation, and concentrations increased in the halothane group in the course of the operation. There was a linear correlation to time between accident and the beginning of the operation. With regard to endocrine parameters, prompt surgical treatment is beneficial.

Diabetic autonomic neuropathy (AN) as a risk factor of surgical procedures has so far been described in case reports, but no controlled clinical studies are known. Therefore, we intended to study systematically the perioperative relevance of the autonomic dysfunction. 32 ophthalmosurgical patients (20 diabetics, 12 non-diabetics) were investigated. Cardiovascular autonomic function was examined preoperatively by a combination of tests (heart rate variations during deep breathing, Valsalva ratio, 30:15 ratio, postural hypotension, sustained hand grip). A scoring system based on these tests provided the staging of the autonomic involvement of the patients (AN score). The anaesthesiological management (thiopentone, N2O, halothane) and the operative procedure (vitrectomy) were uniform. A significant correlation was found between the AN score and the coefficient of variation of the systolic (r = 0.70, p less than 0.001) resp. the diastolic (r = 0.52, p less than 0.01) blood pressure during anaesthesia. No correlation was found between the intraoperative variability of the arterial blood pressure (coefficient of variation) and the age of the patients resp. the preoperative value of the blood pressure. In diabetics with severe autonomic neuropathy (AN score greater than 5) hypotensive reactions were seen very often during the operation. The results demonstrate that the haemodynamic stability in the perioperative period depends on the severity of the autonomic dysfunction. Diabetics with severe autonomic neuropathy have a high risk of blood pressure instability. Non-invasive diagnostic methods allow to identify these patients preoperatively.

A case is reported where a reusable red rubber tube was obstructed by a plastic capsule. This capsule was part of a washing machine for cleaning of reusable anaesthetic equipment. As a consequence we recommend the examination for free passage of each endotracheal tube before use.

The "Lifeway" is a device for rescue breathing consisting of a mouthpiece for the rescuer, a non-rebreathing valve, a mouth-sealing cap and a glosso-palatinal tube (GPT) reaching into the patient's mouth. 54 patients--22 toothless and 32 with firm teeth--were ventilated mechanically via the original "Lifeway", via a variant with additional side-holes in the GPT, and, for comparison, via anaesthesia mask plus oropharyngeal airway and via endotracheal tube. Ventilation was sufficient: The arterial oxygen saturations, measured by pulse oximetry, and the end-tidal CO2 partial pressures were equal to those during ventilation via mask. Placing the modified "Lifeway" in toothless patients was significantly easier than placing the original and as easy as placing the mask; with the patients having firm teeth there were no significant differences. The incidence of obstructions, as registered by impediments to exhalation and by increases in peak inspiratory pressure, was significantly less frequent with the modified device, since the tongue could be "scooped" to a ventro-caudal direction if necessary. The modified "Lifeway" was as effective as the combination of anaesthesia mask and pharyngeal airway. The problems of the latter are, however, avoided; the use of the device by laymen thus seems feasible.

50 non-premedicated ASA class I or II patients were allocated randomly into two groups and received either a variable infusion of propofol or midazolam for sedation during orthopaedic surgery with regional blockade. To achieve a well-sedated patient with eyes closed and able to follow commands, the dose requirements for propofol were 1.25 mg/kg +/- 0.5 as a loading dose followed by a mean infusion rate of 3.17 mg kg-1 h-1 +/- 1.4 and for midazolam 0.073 mg/kg +/-0.02 and 0.074 mg kg-1 h-1 +/- 0.14. Steady-state plasma concentrations of propofol averaged 1.23 micrograms/kg +/- 0.75 and of midazolam 134 ng/ml +/- 62. Recovery was significantly shorter for propofol: 3.42 +/- 2.5 versus 8.05 min +/6.2 for midazolam. Perioperative cooperation was similar in both groups providing good or excellent conditions in 76% with propofol and in 52% with midazolam. 2h after discontinuation of the infusion 92% of the propofol patients were alert, while 36% of the midazolam were sleeping again. Cardiovascular effects of both drugs were minimal; however significant respiratory depression and/or airway obstruction developed in both groups (propofol 48%, midazolam 52%) requiring therapeutic intervention. Additional undesirable effects were: severe cough (propofol 40%, midazolam 20%), inadvertent movements (propofol 36%, midazolam 24%), confusion (propofol 24%, midazolam 20%), euphoria (propofol 44%), pain on injection (propofol 32%). The results of the study indicate that both drugs are useful and controllable sedative agents for surgery under regional anaesthesia, provided that measures for continuous monitoring of respiration and emergency care are guaranteed.

The bronchoscopic examination of the upper respiratory tract is thought to be of major value recognizing and determining the severity of an inhalation injury in burn patients. From clinical observation however it can be questioned if the initial bronchoscopic aspect has indeed any prognostic significance concerning soon or later developing pulmonary complications in those patients. In 15 burn patients with inhalation injury the endoscopically evident lesions of the respiratory tract were classified and documented by photography. Additionally bronchus biopsies for histological examination were taken from different levels of the bronchus tree and a bronchoalveolar lavage (BAL) was performed to gather lung cells of peripheral lung areas. Summarizing the results no firm relations between macroscopically classified degrees of respiratory damage and histopathological diagnosed destructions were found; patients, however, whose differentiation of BAL cells showed an extreme neutrophilia developed progressive lung insufficiency (ARDS) a few days later.

From 1984 to 1988 22 patients with preeclampsia and HELLP syndrome were treated in our ICU. The HELLP syndrome is defined as preeclampsia complicated by thrombocytopenia, hemolysis and disturbed liver function. 3 patients developed a severe DIC with consumption of hemostatic potential. One patient died in multiorgan failure having a consumption coagulopathy, liver rupture and renal failure. To prevent severe hemostatic complications, it is essential to start therapy of DIC as soon as possible by inhibition of the activated coagulation system. Bleeding caused by blood coagulation disorders can occur spontaneously and during operative treatment. Epidural or spinal anaesthesia should be avoided in patients with HELLP syndrome. Because of severe complications such as respiratory failure, diffuse bleeding caused by DIC and progressive deterioration of the renal and liver function in most of the cases, patients with HELLP syndrome require a close cooperation between obstetrics and anesthesist.

The estimation of serum digoxin is a usual method in intensive care. In a case report the detection of digoxin-like-immunoreactive-factor (DLIF) is shown, which gives false high levels. DLIF is observed in renal damage, high cardiac activity, pregnancy and newborn.

The use of local anaesthetic mixtures in regional anaesthesia has been discussed controversially. This assumption led us to conduct an inquiry on anaesthesiologist opinion on local anaesthetic mixtures. The study was performed on 131 anaesthesiologists answering a questionnaire. It was asked how often and how many procedures of regional anaesthesia were performed, whether local anaesthetic mixtures were used or not, and what were the most common mixtures. Other questions were in what kind of regional anaesthesia mixtures were applied, and which causes led to the use of local anaesthetic mixtures. Local anaesthetic mixtures were used by 70.2% of the anaesthesiologists who responded. Generally, however, parent components were preferred (88.3%). The types of regional anaesthesia in which mixtures were applied, were blockades of plexus brachialis (50.4%), spinal anaesthesia (29.0%), and epidural anaesthesia (28.4%). Locally applied anaesthetic mixtures - in 40.5% a mixture of bupivacaine and prilocaine and in 38.2% a mixture of bupivacaine and mepivacaine - were used in 58.0% because of their short latency and their long duration. In 27.5% the reply was that the anaesthesiologists used such combinations since in these the maximal doses of the parent components were not exceeded. In 22.9% it was argued that mixtures were less toxic than the parent components. On the other hand, the application of local anaesthetic mixtures was rejected because of their unpredictable effect (33.6%), and also to avoid local anaesthetic interactions (13.7%). The results of the inquiry demonstrate that the use of local anaesthetic mixtures in regional anaesthesia is common practice. However, mixing local anaesthetics may produce unpredictable interactions. We conclude that mixtures of local anaesthetics should be used only in exceptional cases.