Der Internist
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The demographic development and ongoing improvement of surgical techniques result in an increasing number of high risk elderly patients undergoing surgery. The anesthesiologist has an important role within the management of these patients, because apart from the present illness resulting in a surgical intervention the anesthesiologist has to assess and treat the pre-existing medical disorders in the perioperative period. ⋯ The adequate perioperative anesthesiological management can result in the avoidance of intensive care treatment. A very often underestimated topic is the sufficient perioperative pain treatment of these high risk elderly patients.
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Initiation of effective cardiopulmonary resuscitation (CPR) at the earliest possible moment is the most important determinant of prognosis for prehospital cardiac arrest. The prognosis is essentially defined by two parameters: survival to hospital admission and survival to discharge. ⋯ Further aspects of CPR have recently received increased attention: on the one hand, changed study status regarding the use of antiarrhythmic agents (especially amiodarone), on the other hand, administration of vasopressin during resuscitation, and finally, the efficacy of mild hypothermia following prehospital cardiac arrest. These aspects represent the main subject of the present overview, which also addresses the latest revision of the International Liaison Committee on Resuscitation (ILCOR) guidelines on CPR that resulted in corresponding changes in the European Resuscitation Council (ERC) guidelines.
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Irrespective of improved medical and interventional therapeutic options, mortality among patients with acute heart failure and cardiogenic shock has remained disappointingly high. Early diagnosis and rapid initiation of basic treatment measures to improve hemodynamics and metabolism are of vital importance until causal therapy, e. g. revascularization, is initiated. ⋯ Continuous hemodynamic monitoring to tailor fluid therapy, new drugs, and prognostic markers have been developed for the treatment and monitoring of cardiogenic shock, all of which await testing in larger-scale studies. Ongoing challenges remain the right ventricular pump failure or hemodynamically compromising arrhythmia which may be either cause or consequence of cardiogenic shock.
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Acute pulmonary failure by definition excludes cardiac insufficiency as the pathogenetic mechanism involved in the development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). The systemic inflammatory reaction underlying acute pulmonary failure has many etiological causes. One of the most important trigger mechanisms is sepsis. ⋯ Knowledge of the mechanisms has led to the concept of protective ventilation, which exerts both prophylactic and therapeutic effects. Protective ventilation is an integral part of a bundle of therapeutic intensive care measures. Both constitute the essence of management of acute pulmonary failure.