Der Anaesthesist
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Every action taken by a physician comes under the jurisdiction of the courts. The physician is sentenced when he offends against the duties of care, set down by the respective standard, or when he carries out treatment without having first obtained the patient's consent. Using the examples of many decisions made by the chief justice and the supreme court relating to the field of anaesthesia, this paper sets out to indicate which rules on diligence apply in this area. ⋯ The burden of proof for fulfillment of this obligation lies with the physician. The final part of the paper is a discussion of the documentational obligations, which are important for litigation on the physician's liability. A description of a variety of topics from a physician's everyday work is also given.
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Impaired pulmonary gas exchange can result from lung parenchymal failure inducing oxygenation deficiency and fatigue of the respiratory muscles, which is characterized by hypercapnia or a combination of both mechanisms. Contractility of and coordination between the diaphragm and the thoracoabdominal respiratory muscles predominantly determine the efficiency of spontaneous breathing. Sepsis, cardiac failure, malnutrition or acute changes of the load conditions may induce fatigue of the respiratory muscles. ⋯ As with APRV, alveolar ventilation is maintained even if the spontaneous breathing efforts of the patient cease, which improves the safety of both modes of respiratory therapy. The contribution of spontaneous breathing to total minute ventilation may be important, since a decreased shunt and improved VA/Q relationship have been observed in experimental non-cardiogenic lung oedema. These data give support to the concept that spontaneous breathing should be maintained and augmented in the setting of acute respiratory failure.
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In the presence of completely dry soda lime volatile anaesthetics will decompose to carbon monoxide (CO). In an in vitro study, the absorbent (soda lime, ICI) was dried with a constant gas flow of 11/min oxygen for 120 h. The weight loss during the drying was 17.1%. ⋯ The temperature inside the absorbent rose from the ambient temperature (19.8 degrees C) to a maximum of 52.1 degrees C during CO production and decreased when the CO production lowered after approximately 1 h (all anaesthetics). During CO production no measurable concentration of halothane left the absorber. After passing through the absorbent the concentrations of isoflurane and enflurane were slightly lower than the corresponding concentrations in the fresh gas measured before absorption.
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Comparative Study
[Comparative study of the efficiency of bacterial filters in long-term mechanical ventilation].
Two commercially available bacterial filters to be used as part of the mechanical ventilation unit during anaesthesia were tested for hygienic criteria. Manufacturers claim that bacterial breathing filters have a filtration capacity of about 99.995%, so that there would be no need for thermal disinfection of tubing and ventilation circuits after each use. One filter is designed for a single use only, the other can be used up to 24 times after sterilisation. Both filters consist of hydrophobic glass fibres. ⋯ The use of bacterial filters during mechanical ventilation reduces the probability of bacterial contamination, but does not make sterilisation of the tubes and ventilation circuit unnecessary.
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We describe unexpected episodes of paced tachycardia in two patients with rate-responsive pacemakers during anaesthesia. Five months after a heart transplant and implantation of a pacemaker a 43-year-old patient suffered cardiac tamponade as a result of chronic pericarditis. The second case involved embolic occlusion of the femoral artery in a 33-year-old female patient previously operated on for tricuspid valve replacement and implantation of a pacemaker. In both cases induction of anaesthesia was performed with fentanyl, etomidate and vecuronium. Following intubation and mechanical ventilation, the heart rates (HR) of the two patients increased to 140 and 130 min-1 respectively. This was interpreted as a sign of inadequate anaesthesia, and therefore additional doses of fentanyl and etomidate were given, with no effect on the tachycardia. After exclusion of other possible reasons for this complication such as hypokalaemia, hypercapnia, hypoxaemia or allergic reactions, unexpected functioning of the rate-responsive pacemakers due to thoracic impedance changes was assumed. Minute ventilation was reduced, lowering paced HR in 3-5 min. ⋯ These case reports suggest that anaesthetic management affects the action of rate-responsive pacemakers, causing haemodynamic complications, and inadequate interventions by the anaesthesiologist. Thus, it is necessary for anaesthesiologists to make a preoperative evaluation of the underlying medical disease and the type of pacemaker in order to adjust anaesthetic management accordingly and to understand the haemodynamic responses that may occur during the perioperative period. Preoperative programming to exclude the rate-responsive function is advised.