Der Anaesthesist
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GOAL OF THIS REVIEW: We review the recent literature and our experience in order to determine how one can recognize and handle patients with difficult endotracheal intubation.
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Acute respiratory failure is characterised by mismatch of ventilation with perfusion (VA/Q). The multiple inert gas elimination technique (MIGET) is a complex method which allows the description of a virtually continuous distribution of VA/Q ratios. We investigated VA/Q relationships in patients admitted to the intensive care unit due to acute respiratory failure and thus requiring for mechanical ventilation. ⋯ The impairment of oxygenation in patients with acute respiratory failure is due to several pathophysiological mechanisms: increase in intrapulmonary shunt, VA/Q-mismatching and dead space ventilation, according to the severity of lung failure. We conclude from our results that the prevention and/or reduction of non-ventilated lung areas (atelectasis) is an outstanding therapeutic strategy in the treatment of patients with acute respiratory failure. From this point of view, several techniques of systemic changes in body position should be integrated as supportive therapeutic strategies.
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Experimental studies have shown that in traffic accidents with frontal impact the new airbag system can significantly reduce the incidence of severe injuries and fatal outcome. The question of whether the airbag itself induces specific patterns of injury needs further investigation. Two cases of traffic accidents with airbag protection are presented here. ⋯ These have not been described before. It is concluded that patients who were involved in traffic accidents with airbag deployment have to be hospitalized and followed up carefully over time, even though they are initially stable, as potentially fatal sequelae of deceleration trauma can occur later. In our opinion it is not possible to estimate the severity of airbag-associated injuries with conventional methods.
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Numerous basic drugs are extensively bound to alpha 1-acid glycoprotein. Fentanyl, with a pKa value of 8.43, is also a basic drug. Protein binding studies have yielded contradictory results concerning binding of fentanyl to alpha 1-acid glycoprotein. ⋯ In agreement with the findings of former studies, protein binding of fentanyl depended on albumin, total protein and apolipoprotein B concentrations. Due to unspecific binding of fentanyl by hydrophobic interactions, a major role of albumin, which amounts to about 60% of total protein, seems to be evident. Determining fentanyl protein binding by equilibrium dialysis, volume shifts must be taken into account if calculation is based on fentanyl concentrations in plasma (serum) and buffer after dialysis, and an appropriate buffer must be used.