Der Anaesthesist
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The action profile of succinylcholine is unmatched even 50 years after its introduction into anaesthestic practice. This is probably why succinylcholine, despite its many and partly life-threatening side-effects, is still considered to be indispensable by many anaesthetists and emergency doctors. The main indication for succinylcholine--the facilitation of endotracheal intubation in patients considered to be at an increased risk of aspiration of gastric fluid, e.g. patients undergoing a Caesarean section or presenting with an ileus--remains undisputed. ⋯ In the case of an expected difficult airway no muscle relaxant should be given, because severe hypoxaemia in these patients probably can only be prevented by a professional airway management. Succinylcholine is no longer an option in elective paediatric anaesthesia. The drug, however, retains its value in critical situations where a rapid onset but a short duration of action is of prime importance.
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The development of adult respiratory distress syndrome (ARDS) complicates the treatment of patients with severe head injury, since special therapeutic strategies for both conditions might lead to a "conflict of interest". We report on the intensive care treatment of a young man who suffered severe brain injury (Glasgow Coma Scale = 3) due to a traffic accident and simultaneously developed ARDS from the aspiration of gastric content. We performed extensive monitoring of cerebral hemodynamics and metabolism (intracranial pressure measurement, jugular bulb oxymetry, estimation of arterial-jugular bulb lactate concentration difference) to prevent cerebral hypoxia and to control cerebral hyperemia. ⋯ After withdrawing the analgo-sedation the patient's vigilance rose continuously. The patient was transferred to a rehabilitation ward 33 days after admission to the intensive care unit. The combination of ARDS and severe brain injury needs special treatment, which includes extensive monitoring techniques to find a solution for therapeutic conflicts.
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Transient neurologic symptoms (TNS) after spinal anesthesia (SPA) is defined as back pain with radiation or dysesthesia in the buttocks, thighs, hips and calves, occurring within 24 h after recovery from otherwise uneventful SPA. The symptoms last for about 1-3 days but neurophysiologic evaluation does not show pathologic findings. The type and the preparation of the local anesthetic drug (baricity, concentration, additives or preservatives) are most often discussed as the underlying cause of TNS. ⋯ Prilocaine and bupivacaine for SPA are associated with less TNS than lidocaine and mepivacaine. For the other local anesthetics there were not enough comparative trials to give conclusive recommendations.
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Between 40 and 90 cardiopulmonary resuscitations are performed per 100,000 inhabitants each year in western industrialised nations. In 50-70% of these patients, either fulminant pulmonary embolism or acute myocardial infarction is the underlying cause of cardiac arrest. Based on this fact, thrombolysis may represent a new and effective causal therapeutic strategy in patients suffering from cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. ⋯ This coagulation imbalance is thought to be responsible for postresuscitation cerebral microcirculatory reperfusion disorders in patients after cardiac arrest and cardiopulmonary resuscitation. In summary, recent clinical and experimental data focusing on thrombolysis during cardiopulmonary resuscitation strongly indicate, that thrombolysis may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms.