Der Anaesthesist
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The wide variability of clinical symptoms and the ongoing difficulties concerning the rapid and specific laboratory diagnosis of sepsis, contribute to the fact that sepsis primarily remains a clinical diagnosis. To contribute to a more tailored antibiotic coverage of the patient early on in the course of the disease, modern diagnostic concepts favour the qualitative and quantitative molecular biological detection of blood stream pathogens directly from whole blood. ⋯ In the short term, such tests will not substitute conventional blood culture despite their superior rapidity and sensitivity, mainly because of higher cost. The amazing speed of ongoing scientific developments means, however, that techniques that might appear complicated, labour intensive, and costly today, will develop to become the future standards in the microbiological diagnosis of patients with sepsis and septic shock.
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Acute confusional states (delirium) occur in up to 80% of patients in the intensive care unit. Delirium is an important independent prognostic determinant of hospital outcome, including duration of mechanical ventilation, nursing home placement, functional decline and death. ⋯ Recently, a number of new screening instruments have been validated for the monitoring of delirium in non-communicative patients receiving mechanical ventilation. Critical care patients should be routinely assessed for delirium and treated immediately using available preventive and therapeutic measures, both pharmacological and non-pharmacological, to improve the clinical course.
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Review
[Management of hemostasis disorders after extracorporeal circulation. A clinical therapy algorithm].
After cardiac surgery with extracorporeal circulation, approximately 20% of patients show significant bleeding tendencies and 5% require re-intervention. In 50% of patients undergoing re-operation, no surgical cause can be determined, suggesting coagulopathy after cardiopulmonary bypass (CPB). ⋯ The intervention with plasma products, coagulation factor concentrates and hemostatic drugs after extracorporeal circulation are described. Extensive bleeding history as well as the efficacy and side effects of antifibrinolytic treatment are discussed.
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In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.