Der Anaesthesist
-
After neurosurgery patients often need to be sedated and ventilated in the intensive care unit (ICU). However, rapid postoperative recovery and neurological examination are particularly important for the early recognition of complications. In this retrospective study two different strategies of anaesthesia technique and ICU sedation (fentanyl-midazolam versus remifentanil-propofol) were compared. ⋯ This retrospective study demonstrates that remifentanil-propofol anaesthesia and ICU sedation are superior to the combination of fentanyl and midazolam in terms of ventilation time and length of ICU stay. Moreover, the use of fentanyl-midazolam may lead to unnecessary CT scans.
-
Presently and even more in the near future more cancer patients will be treated at home especially in the final stage of their disease. For this reason the prehospital emergency system will be confronted with the specific needs of these patients. Palliative care is not part of the German model of post-graduate training regulations for emergency medicine and palliative care teams (PCT) are only involved in the treatment of cancer patients in emergency situations. ⋯ Our data demonstrate that care of cancer patients in the final stage of the disease is relevant in emergency medicine. These patients are in need of help based on principles of palliative care. Under these circumstances cooperation of the medical disciplines (emergency and palliative medicine) concerned seems to be necessary. This may increase the possibility for patients to stay at home for the last days of their life. Because of this we are convinced that basic knowledge of palliative care should be integrated into the German model of post-graduate training regulations for emergency care. Combining parts of the curricula (palliative and emergency medicine) it would be possible for emergency physicians to guide their treatment by the ideas and strategies of palliative care. But we are also convinced that the system of PCT should increase and become more involved in prehospital care in emergency cases of palliative care patients.
-
Case Reports
[Septic shock due to vancomycin-resistant enterococci infection. Tigecycline monotherapy].
Adequate antimicrobial therapy is of crucial importance for the survival of critically ill patients with severe nosocomial infections. Tigecycline is an important therapeutic option for the treatment of infections caused by multi-resistant Gram-positive and Gram-negative bacteria including vancomycin-resistant enterococci (VRE). A large randomised study (patients with APACHE-II-score >30 excluded/mean APACHE-II-score 6) demonstrated that tigecycline is not inferior to imipenem/cilastatin for treatment of complicated intra-abdominal infections. ⋯ As the site of anastomotic leakage was very small and could not be exactly identified, irrigation-suction drains were placed followed by closed postoperative continuous lavage. The pathogen responsible was identified as a vancomycin-resistant Enterococcus faecium, therefore monotherapy with tigecycline was started which resulted in microbiological response and clinical cure. Tigecycline is a new therapeutic option for the treatment of intra-abdominal infections and from an economic point of view financially rewarding when used as monotherapy.
-
Randomized Controlled Trial Multicenter Study
[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study].
While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. ⋯ The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.
-
Laryngeal and pharyngeal complaints are among the subjective problems most frequently reported by patients after general anaesthesia involving endotracheal intubation, others being pain, nausea and vomiting. Hoarseness, sore throat, and vocal cord injuries restrict patients' social lives, and in some cases also their working lives. ⋯ Knowledge of the pathophysiological aspects and other relevant factors associated with laryngopharyngeal morbidity are essential cornerstones of quality assurance in perioperative respiratory tract management. In this review specific sections are devoted to the implications of anaesthesia involving endotracheal intubation and laryngeal masks for laryngopharyngeal morbidity, and also particular aspects of thyroid gland surgery, cardiothoracic and bariatric surgery and obstetric and paediatric anaesthesia, and medicolegal aspects.