Der Anaesthesist
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Randomized Controlled Trial Comparative Study Clinical Trial
[Incidence and quality of dreaming during anesthesia with propofol in comparison with enflurane].
Since the introduction of propofol into clinical practice, dreaming during general anaesthesia has been frequently reported with this drug. We investigated the incidence and character of these dreams with regard to distinction from intraoperative awareness and in comparison with habitual dreams or dreams during general anaesthesia with enflurane. ⋯ We conclude that sensory experiences during propofol anaesthesia are not stimulus-related perceptions or awareness, but dreams similar to normal ones. In view of the absence of clear signs of stimulus-related response, we presume that dreaming is a specific side effect of propofol. Because of the absence of difficulties, dreaming during propofol anaesthesia appears not to be a disadvantage with regard to the quality of anaesthesia.
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The on-scene performance during all missions of the emergency physician-operated rescue helicopter and mobile intensive care unit based at a large-city hospital over a period of 1 year was retrospectively analysed; 2,254 hospital discharge reports were available (92% of the patients treated by the emergency physicians [n = 2,493]). The following parameters were investigated: reliability of the primary diagnosis established by the emergency physician (by comparison with the discharge diagnoses); initial on-scene therapeutic measures; means of transportation (with or without accompanying emergency physician); and level of care of the target hospital. ⋯ In the context of quality management measures, a careful evaluation of on-scene diagnoses, therapeutic measures, and decisions made by the emergency physician is a suitable procedure for identifying systematic errors. A high percentage of correct diagnoses and therapy at the emergency site can only be ensured by clinically experienced physicians who constantly deal with patients with acutely life-threatening conditions.
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Case Reports
[Treatment reduction in intensive care. "Allowing the patient to die" by conscious withdrawal of medical procedures].
The conversion of an "attempt to treat" to "prolongation of dying" represents an important problem in modern intensive care. If the actual or presumed will of the patient is unknown, the physician has to decide about the extent of treatment in a paternalistic manner. In these difficult decisions the physician has to consider prognosis, and certainty of prognosis and has to carefully balance between the right to live and the right to die. ⋯ If the situation is hopeless and further medical interventions are futile, then allowing the patient to die by therapy reductions is not only a possibility but a mandatory act of humanity. In that case it does not matter whether new treatment modalities are abandoned or whether already instituted medical measures are withdrawn. In clinical practice, however, the "fine tuning" of therapy reduction has to be tailored to the individual case and largely depends on prognostic certainty.
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The inhalational anaesthetic fluor-methyl-trifluor-1-(trifluoromethyl)-ethylether sevoflurane has been known for more than 20 years and is structurally related to the currently available volatile anaesthetics. This anaesthetic is characterized by a low blood/gas partition coefficient of 0.69 and high fat solubility, leading to a sharp rise in alveolar concentration and quick anaesthesia induction. As opposed to desflurane, sevoflurane does not boil at ambient temperature, thus making a special vaporizer unnecessary. ⋯ As opposed to methoxyflurane, which may be nephrotoxic due to its microsomal metabolism in kidney tissue, sevoflurane does not seem to cause clinical inhibition of renal function even at plasma fluoride levels above 50 mumol/l, a concentration thought to be associated with renal tubular impairment. A possible reason for this observation is lower metabolism of sevoflurane within renal tissues. Due to its quick onset and fast elimination, sevoflurane is an interesting new volatile anaesthetic offering various clinical advantages.