Der Anaesthesist
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Mechanical ventilation and positive end-expiratory pressure (PEEP) are considered to be the cornerstones of therapy for acute lung failure and acute respiratory distress syndrome (ARDS), when high levels of PEEP are applied in order to maintain or restore oxygenation, despite the fact that aggressive mechanical ventilation can markedly affect cardiac function in a complex and often unpredictable fashion. As heart rate usually does not change with PEEP, the entire fall in cardiac output is a consequence of a reduction in left ventricular stroke volume (LVSV). ⋯ Mechanical ventilation with PEEP, like any other active or passive ventilatory maneuver, primarily affects cardiac function by changing lung volume and intrathoracic pressure (ITP). In order to describe the direct cardiocirculatory consequences of respiratory failure necessitating mechanical ventilation and PEEP, this review will focus on the effects of changes in lung volume, factors controlling venous return, the diastolic interactions between the ventricles and the effects of intrathoracic pressures on right and left ventricular function.
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Historically, calculation of staffing requirements for anesthesia has developed from index numbers derived from the workplace method to the service performance method (XX time). The DRG revenues result from an average calculation of costs that results from an assumed calculation of staffing requirements based on the service performance method. ⋯ In a second step the services rendered in a specified organization are then assessed for efficiency and if necessary optimized. Just as it applies to the whole clinical center, in departments of anesthesiology DRG revenues should be brought in line with the actual costs.
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Classical adult type rapid sequence induction (RSI) intubation is not always appropriate in children. In newborns, infants and small children, limited cooperation during pre-oxygenation, reduced respiratory oxygen reserves, increased oxygen demand and a tendency for airway collapse, easily lead to hypoxaemia after induction of anaesthesia. Gentle mask ventilation with pressures not exceeding 10-12 degrees cm H(2)O allows oxygenation without the risk of gastric inflation and aspiration. ⋯ Application of cricoid pressure does not reliably prevent pulmonary aspiration. In children cricoid pressure clearly interferes with smooth induction of anaesthesia, results in difficult mask ventilation and intubation as well as provokes bucking and straining and, therefore, should not be routinely used. Key features of RSI intubation for children are effective induction of deep anaesthesia followed by profound muscle paralysis, careful mask ventilation and gentle tracheal intubation under optimised conditions.