Anasthesie, Intensivtherapie, Notfallmedizin最新文献

Method: In 56 patients undergoing arthroscopy of the knee blood pressure (BP), heart rate (HR) and plasma catecholamines were measured during induction of anaesthesia. To a standard treatment including etomidate (K), either 1 (A1), 2 (A2) or 3 (A3) mg alfentanil were added. The control-group included 8 patients, the other groups consisted of 16 patients. Blood pressure and heart rate were measured the day before anaesthesia (T1), at the arrival in the operation theatre (T2), 1 minute after the induction (T3) and 1 minute after intubation (T4). Catecholamines were analysed at T2 and T4. -

Results: At T1 and T2 no significant differences were measured. The control-group had a significant rise of BP, HR and adrenalin at T4. In group A1 (1 mg alfentanil) BP and catocholamines remained at the same levels, HR rose significantly. In group A2 all parameters did not change. The group A3, BP dropped significantly, whereas the other parameters remained stable.-

Discussion: 2 mg Alfentanil given 1 minute before endotracheal intubation depress the sympathoadrenergic reactions but do not impair the circulation.

Postoperative artificial ventilation by using an endotracheal tube may cause a pulmonary infection. A possibly necessary permanent sedation and relaxation may result in an additional danger for the patient. The principle of the "iron lung" represents an alternative to endotracheal artificial respiration, which applies especially to endangered patients who are under postoperative artificial respiration. After an abdominal operation five patients have been extubated and artificially respirated by using the "iron lung" principle while not being able to breath by themselves. The degree of the sedation was monitored both intraoperatively and postoperatively using an automatic EEG classification. The performance spectrum of the respiratory curve enabled very early detection of the onset of spontaneous respiration.

In this study chest radiographs of 105 patients from an intensive care unit are reviewed to investigate the value in differential diagnosis and control of the course of pulmonary dysfunction. The most helpful criterion in differential diagnosis was the time course of the visible infiltrate on the chest film. Contusion of the lung and aspiration pneumonia showed a steady decrease after an initial maximum, pneumonia and ARDS developed within several days to a maximal infiltration. A rise in extravascular lung water presents with various quickly changing patterns. Pleural effusion, appearance and localisation of the infiltrate are of less value in differential diagnosis. The connection to clinical and anamnestic features is important. There was a good correlation between time course of the radiological visible infiltrate and the intensity of artificial respiration.

Coagulase-negative staphylococci have gained increasing importance in burns, whereas interest is no longer focussed on Pseudomonas bacteria. By means of microbiological analysis of swabs taken from patients, environment and staff, we trailed the routes of infection in an intensive-care unit for burns. Analysis of patients: In 27 out of 11 patients the same biotype of Staphylococcus epidermidis could be identified; 22 of these occurred in swabs from wounds. The phagotypification of Staphylococcus aureus showed the same phagotype in 28 out of 41 swabs taken from infected wounds of 10 patients. The pathogen mostly caused the destruction of already healed grafts in a later phase of the treatment. Further microbiological analysis showed a severe infestation of the patients by enterococci. Analysis of environment: Here, greatly increased counts of coagulase-negative staphylococci of the same lysotype as in the patients could be demonstrated. Analysis of staff: The naso-pharyngeal area is of minor importance in the spreading of germs, whereas that of protective clothing and especially the hands should be considered to be more crucial. Regular environmental tests enable rapid detection of hygienic errors so that appropriate countermeasures can be taken.

The duration of action of a supplementary dose of Atracurium 0.125 mg/kg after an initial dose of Atracurium 0.5 mg/kg respectively Alcuronium 0.25 mg/kg was investigated in 2 groups of 7 patients each. The average duration of action of Atracurium after Alcuronium (44.62 +/- 9.95 min) was 1.75 times longer than that of Atracurium after Atracurium (25.49 +/- 4.08 min). The difference is statistically significant (p = 0.05). For the clinical application of a combination of Atracurium with Alcuronium, 2 conclusions which might appear contradictory can be considered: 1. the pretreatment with Alcuronium can enhance intentionally the duration of action of Atracurium and spare total dosage of muscle relaxants at the same time. Prompt antagonism of muscle blockade of Atracurium remains unchanged according to our experience. 2. the pretreatment with Alcuronium may be dangerous whenever Atracurium is administered close to the end of the operation because of the possibility of prolonged postoperative muscle relaxation.

The halogenated hydrocarbons halothane, enflurane and isoflurane are used extensively. Like every other anaesthetic, these inhaled agents are not devoid of side effects, most of which are undesirable. This review summarises the similarities and differences between the actions of these vapours. Although isoflurane appears to be more advantageous than enflurane and halothane in certain patients, isoflurane is no panacea and the question of which agent to choose still has to be answered for every patient. A note of caution is warranted against the further use of halothane in adults, as halothane offers no advantages when compared to enflurane and isoflurane but carries a higher risk of hepatotoxicity. However, in children halothane remains the halogenated agent of first choice, when anaesthesia is induced via face mask.

Methadone, a potent long-acting opioid analgesic, is only seldom prescribed for postoperative pain relief in Germany. It was the aim of the present investigation to evaluate its efficacy and to establish an adequate dose range using intravenous patient-controlled analgesia (PCA), as well as to determine possible drug interactions with the antipyretic analgesic metamizol (dipyrone). 120 patients recovering from elective major abdominal, gynaecological or orthopaedic surgery under standardized balanced anaesthesia were randomly allocated to three groups to self-administer intravenous 1-methadone. Demand doses were 0.573 mg (group LD), 1.145 mg (group HD) or 0.573 mg to which 50 mg metamizol (dipyrone) were added (group LM). Infusion rate was set to 0.137 mg 1-methadone/h in every group, lockout time was 1 min. Hourly maximum dose was set to 5.95 mg 1-methadone/h. During an average PCA duration of 21 hours patients demanded mean dosages of 16.4 mg (LD), 18.7 mg (HD) or 13.4 mg (LM) 1-methadone. Although individual variation in drug consumption was high, effective pain relief was possible in all cases. Cardiovascular and respiratory status during the observation period was always normal. 88-93% of patients preferred PCA in comparison with earlier experienced conventional postoperative pain treatment. It is concluded that patients are able to control adequate drug consumption, i.e. to avoid overdosage, by adjusting demand frequency if variable demand dosages are offered. Thus 13-19 mg 1-methadone per day can be recommended as reasonable dose range for pain relief during the early postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

In the last few years new narcotic agents with more favourable pharmacokinetic properties have been introduced into clinical practice. Short half-lives and smaller distribution volumes facilitate control of anaesthetic depth and shorten the recovery period. One of these narcotics is alfentanil. This study was performed on the effects of alfentanil when used during anaesthesia in infants under the age of one year. After induction and relaxation alfentanil 20 mcg/kg were given i.v. initially. The same dose was repeated as needed until 15 min. before surgery ended. The patients were ventilated with N2O/O2 (2:1). Muscle relaxation was maintained at 90-95% with vecuronium, monitoring "train of four" twitch response. The effects of alfentanil on airway pressure, pulse and blood pressure were measured during and without muscle relaxation. The time from end of surgery until full recovery was recorded. Percutaneous CO2-tension was measured in the recovery room. There were no clinical problems with induction or recovery. The average time until the infants opened their eyes and started moving was 1.8 min. No significant changes in pulse and blood pressure occurred during surgery. Airway pressure showed minimal increases when muscle relaxation decreased. These data suggest that alfentanil/N2O anaesthesia can be considered as an alternative if halogenated hydrocarbons are rated unsuitable in paediatric anaesthesia.

A genetically intact newborn suffered from methaemoglobinaemia after delivery under pudendum anaesthesia with prilocaine. Complete restitution was promoted by i.v. applied ascorbic acid and thionine. This is of special importance because in this case methaemoglobinaemia was not produced by medication of the patient herself but must be attributed to the local anaesthesia of the mother with prilocaine. The special sensitivity of newborn and infants, as well as the use of possible treatment methods as described in literature, are discussed.