Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie : AINS
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Anasthesiol Intensivmed Notfallmed Schmerzther · Jan 2003
Review[Emergency medicine -- new concepts and therapies improve outcome from cardiac arrest].
According to scientific articles focusing on emergency medicine published in international journals in the past few months, early defibrillation by lay persons, thrombolysis during cardiopulmonary resuscitation (CPR) and treatment with mild therapeutic hypothermia have been identified as relevant, new and clinically important treatment options to improve outcome following cardiac arrest. Early defibrillation using automated external defibrillators by lay persons reduces the time interval between collapse and first attempts at defibrillation and thus improves outcome after prehospital cardiac arrest. Thrombolysis during CPR -- for which the results regarding safety and efficacy are available from nonrandomized trials -- can also be safely performed in case of pulseless electrical activity. ⋯ Mild therapeutic hypothermia, i. e., cooling of cardiac arrest victims to 32-34 degrees C central body temperature for 12-24 h following out-of-hospital cardiac arrest, markedly improves survival rate and neurological outcome. Since this has now been clearly documented in two randomized clinical trials, it can be assumed that this kind of intervention will be recommended and translated into clinical practice soon. In conclusion, new and clinically relevant methods to improve outcome following cardiac arrest are available and can now be widely used clinically.
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Anasthesiol Intensivmed Notfallmed Schmerzther · Jan 2003
Case Reports[Rupture of the trachea after emergency endotracheal intubation].
The rupture of the trachea is a rare but serious complication after endotracheal intubation. We report the case of a 77-year-old severely diseased woman with emergency intubation after development of acute respiratory distress. ⋯ According to the forensic autopsy the secondary perforation is probably a consequence of intubation or a pressure lesion of the tube in combination with a weakness of the membraneous part of the trachea due to impaired microperfusion. Every physician performing an intubation has to be aware of the risk and the consequences of a tracheal rupture.
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Anasthesiol Intensivmed Notfallmed Schmerzther · Jan 2003
[Initial medical treatment by paramedics in combined first aid operations of paramedics and emergency physicians].
The present study was conducted to evaluate the quality of paramedic care and the feasibility and cost-effectiveness of sending a well-trained paramedic team to the sight of a medical emergency to initiate active medical treatment prior to the arrival of the mobile intensive care unit (MICU). ⋯ In this study, a large number of emergency procedures could be performed by the paramedic team within a short period of time (in some cases < 3 min), and adequate effectiveness. Based on our results, the activation of paramedic-staffed first-tier ambulances with shorter response times is recommended in addition to the MICU system.
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Anasthesiol Intensivmed Notfallmed Schmerzther · Jan 2003
[Current status of non-invasive ventilation in German ICU's -- a postal survey].
The status of non-invasive ventilation (NIV) in intensive care units (ICU) in Germany was analysed by a national survey. Questionnaires consisting of multiple-choice and short-answer questions were sent to ICUs of university hospitals, hospitals with >1000 beds, with 500 - 1000 beds, and hospitals with <500 beds separated with regard to different specialties (anesthesia ICUs, surgical ICUs, cardiac surgical ICUs, neurosurgical ICUs, internal ICUs, interdiscipline ICUs). Of the 716 questionnaires sent 223 (32 %) were returned and analysed. ⋯ The reasons to reject NIV were (total 13 %): lack of ventilators (64 %), expenditure of personnel (57 %) and risk of the procedure (11 %). 38 % of the ventilators used were older than 5 years. 56 % of the ICUs were content with the equipment for NIV. 76 % of the ICUs were interested to buy new equipment of NIV. 99 % of the survey have declined NIV as an alternative method of ventilation. In summary we found NIV as an accepted additional method of ventilatory support in respiratory failure in German ICUs. We found no significant increase in frequency of NIV in the last three years.
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Anasthesiol Intensivmed Notfallmed Schmerzther · Jan 2003
Review[Development of opioid tolerance -- molecular mechanisms and clinical consequences].
One often identified effect of opioid administration is that of the development of tolerance to the analgesic effect. While it is generally agreed that tolerance to opioid analgesia does occur, it does not appear to be a limiting factor. Dose escalation in chronic pain therapy is considered to be predominantly a consequence of increasing pain, which is a result of increasing nociceptive input as the disease progresses. The underlying cause of tolerance to opioids, however, as commonly identified in the ICU can be identified as an adaptation process. When the opioid is given continuously several causes of adaptation can be identified, all of which can be traced back to the cellular and molecular level. ⋯ Most likely genetic difference in opioid receptor synthesis and difference in their affinities for various ligands is the cause for the wide margin of dose variability in patients (genetic polymorphism). Once tolerance to the analgesic effect of the opioid is observed and in order to avoid unnecessary further development of tolerance, simultaneous administration of other receptor mediated analgesics is advocated. In the perioperative period strategies like the multimodal analgesic concept is fostered. It consists of the simultaneous administration of low-dose ketamine, co-administration of an alpha 2-agonist, and the administration of a selective COX-2 inhibitor (refecoxib, parecoxib) respectively. In chronic pain therapy combined administration with either dextromethorpharphane, or opioid rotation of a more potent ligand such as methadone, fentanyl TTS or oxycodone is suggested. Since conversion factors are not reliable in opioid rotation, it is best to start off with 50 % of the equivalent dose and rapidly titrate to the desired effect. With regard to tolerance development in the ICU, co-administration of an alpha 2-agonist (clonidine, dexmedetomidine), and daily intermittent cessation of benzodiazepine administration are advocated. Since continuous dosing of an opioid, commonly handled in the ICU setting is more likely to induce tolerance, intermittent administration is advocated. Taken together, there is an abundance of experimental data which suggests, that with every dose of an opioid several adaptive processes are being initiated. Due to genetic polymorphism such adaptation is seen clinically with striking individual different dosages, the degree and the time of onset of tolerance. Although tolerance development may result in staggering doses of an opioid, there is no reason to evade the use of such agents. On the contrary, the concept of multimodal analgesia consisting of the simultaneous use of analgesics with a different mode of action can counteract tolerance development.