Der Anaesthesist
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Review Case Reports
[False positive death certification. Does the Lazarus phenomenon partly explain false positive death certification by rescue services in Germany, Austria and Switzerland?].
Apart from misdiagnosis, the Lazarus phenomenon, a spontaneous return of circulation after cardiac arrest, is a potential cause for false positive death certification. Because of medicolegal consequences and thus a negative publication bias, the incidence of false positive death certification is unknown. As a false positive death certification results in criminal prosecution and thus media interest, numerous media archives in Germany, Austria and Switzerland were searched for such reports. ⋯ As definite signs of death will not have developed only a few minutes after stopping CPR it might be difficult for an emergency physician to definitely certify a patient's death in an out-of-hospital setting with 100% safety. Thus, prehospital death certification poses a risk of error and subsequent legal prosecution of the emergency physician, as a Lazarus phenomenon may still occur in this phase. Delegation of death certification from emergency physicians to qualified physicians in a follow-up examination might increase both legal safety for emergency physicians in the field and patient safety.
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Review Meta Analysis
[Lazarus phenomenon. Spontaneous return of circulation after cardiac arrest and cessation of resuscitation attempts].
In the medical literature the Lazarus phenomenon is defined as the spontaneous return of circulation (SROC) after cessation of cardio-pulmonary resuscitation. Based on published literature recommendations concerning the treatment of patients after cessation of resuscitation and reasons for the Lazarus phenomenon are discussed. ⋯ In the relevant medical literature, the Lazarus phenomenon is a rare occurrence. It seems to be a phenomenon which has often been described in non-medical literature but not published in medical literature. The pathophysiological mechanisms are poorly understood. In the literature several mechanisms are discussed which could be important for this phenomenon, e.g. autopositive end-expiratory pressure, hyperventilation and alkalosis, hyperkalemia, delayed action of drugs and unobserved minimal vital signs. In the literature it is recommended that patients should be passively monitored for at least 10 min after cessation of resuscitation. However, more scientific experimental investigations seem to be necessary to gain a better understanding of this phenomenon.
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The religious organization of Jehovah's Witnesses numbers more than 7 million members worldwide, including 165,000 members in Germany. Although Jehovah's Witnesses strictly refuse the transfusion of allogeneic red blood cells, platelets and plasma, Jehovah's Witness patients may nevertheless benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The present review describes the perioperative management of surgical Jehovah's Witness patients aiming to prevent fatal anemia and coagulopathy. The cornerstones of this concept are 1) education of the patient about blood conservation techniques generally accepted by Jehovah's Witnesses, 2) preoperative optimization of the cardiopulmonary status and correction of preoperative anemia and coagulopathy, 3) perioperative collection of autologous blood, 4) minimization of perioperative blood loss and 5) utilization of the organism's natural anemia tolerance and its acute accentuation in the case of life-threatening anemia.
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The perioperative management of patients belonging to the faith of Jehovah's Witnesses poses two equally difficult problems for physicians due their strict refusal of allogeneic blood transfusions: From a medical point of view everything must be done to avoid fatal anemia and coagulopathy. On the other hand, the physician is confronted with the legal problem even in extreme cases, whether the wishes of the patient, i.e. the religiously motivated right to self-determination, should or even must be followed when despite all preventative measures as described in this case, the risk of fatality is only avoidable by a blood transfusion and therefore represents the only life-saving option. In order to be able to answer this question this article supplies information on the unanimously recognized conditions in the jurisdiction and prevailing legal opinion and derives the consequences for the physician that this does not necessarily signify an unconditional legal obligation in association with a patient directive.
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Because of the high vulnerability of the brain as a primary target, neuroanaesthesia requires a close look at basic physiological principles and factors of influence during surgery and subsequent intensive care. Anticipatory management is crucial for anaesthesia within the scope of neurosurgical interventions: essential components of anaesthesia management must already be prepared before the surgical procedure. Intracranial compliance and pressure determine the patient's fate; accordingly they have to be assessed correctly and measured continuously. ⋯ For the treatment of intracranial hypertension, osmotherapy is still of the highest value. Decompressive craniotomy seems to have become a promising alternative, although this must be judged to date as a last resort therapy. Perioperative care of patients with complex intracranial pathologies thus needs a close interaction and cooperation between the operation theatre and intensive care units in the sense of continuous track anaesthesia.