Der Anaesthesist
-
Gastrointestinal integrity with intact function are of main importance in critically ill patients, and not only as a route of nutritional support. Drugs used for long-term sedation can lead to disordered gastrointestinal motility. In this study we compared the influence of different combinations of analgesics and sedatives on the intestinal function in mechanically ventilated, critically ill patients. ⋯ Therefore, we recommend piritramide or ketamine for analgesia. The basic sedating drug is midazolam, in special cases combined with or replaced by propofol. The position of GABA in long-term sedation is not yet clear, but a lack of side effects on the gastrointestinal tract became evident in this stud
-
For cardio-pulmonary resuscitation there are standardized treatment concepts, but there have been few prospective investigations examining the efficacy of prehospital advanced trauma life support and its effect on the outcome in patients with severe head injury and multiple trauma treated within the German emergency system. The results of this study underline the importance of intensive prehospital treatment and highlight some problems that should be taken into account in future in the training of emergency physicians. METHODS. ⋯ These results demonstrate the importance of advanced trauma life support and show emphatically that the so-called scoop-and-run strategy should be abandoned when resources are available for extended preclinical emergency treatment. On the other hand, we detected some problem areas in the prehospital treatment of trauma victims, such as positioning, immobilization and drug therapy with analgesics and sedatives. These findings allow us to pinpoint specific points that should be stressed in the training of emergency physicians and paramedics.
-
We present a potentially fatal case of acute methaqualone (M) poisoning with very low serum concentrations of M but extremely high levels of its metabolite, 2-methyl-3-(2-hydroxymethyl-phenyl)-4 (3H)-chinazoline (Met-1). A 23-year-old man was admitted to the intensive care unit 2 days after ingestion of 4-5 g M in an suicidal attempt. On admission he was somnolent and poorly responsive to painful stimuli. Physical examination revealed a heart rate of 95 bpm, a blood pressure of 125/65 mmHg, and a normal body temperature. His chest was clear to auscultation, respirations were shallow, and the skin was cyanotic. The electrocardiogram was unremarkable. The chest radiograph showed a normal heart size without pulmonary infiltrates or venous congestion. The pupils were dilated but reactive to light. The neurologic examination was further remarkable for increased limb reflexes, myoclonia, and positive pyramidal signs. During the next 2 days the patient became comatose and developed respiratory insufficiency due to non-cardiogenic pulmonary oedema, which was confirmed by chest radiograph and haemodynamic investigations by means of right heart catheterisation. He required mechanical ventilation for 6 days. Finally, he recovered completely and was discharged in good condition. ⋯ The presented case is the first report of a life-threatening intoxication after M ingestion primarily caused by Met-1. It supports the significance of this metabolite for the toxic effects of the drug. A toxicological screening test based on ELISA proved helpful due to its cross-reactivity with metabolites. In cases similar to ours, resin haemoperfusion may be indicated to remove the metabolites despite low detectable concentrations of the parent substance in the serum.
-
Neoplastic or traumatic lesions of the brain stem or the upper spinal cord frequently cause respiratory insufficiency necessitating permanent mechanical ventilation. If the integrity of the diaphragm and its nerves is not affected, adequate ventilation can be achieved by electric stimulation of the phrenic nerves. Diaphragm pacing systems mean the patients can be independent of ventilator treatment. ⋯ The duration of stimulation was increased stepwise from 1 h a day to full-time stimulation. Three weeks after implantation of the diaphragm pacer system the patient could be totally weaned from mechanical ventilation. After a further 2 weeks it was possible to discharge him from the intensive care unit, and he was then transferred to a rehabilitation centre.