Der Anaesthesist
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Thirty years ago, cardiopulmonary resuscitation (CPR) was primarily developed for otherwise healthy individuals who experienced sudden cardiac arrest. Today, CPR is widely viewed as an emergency procedure that can be attempted on any person who undergoes a cessation of cardiorespiratory function. Therefore, the appropriateness of CPR has been questioned as a matter of the outcome, the patient's preferences, and the cost. The objective of this article is to analyse ethical issues in prehospital resuscitation. ⋯ The standard of care remains the prompt initiation of CPR. However, ethical principles such as beneficence, nonmaleficence, autonomy, and justice have to be applied in the unique setting of emergency medicine. Physicians have to consider the therapeutic efficacy of CPR, the potential risks, and the patient's preferences.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Remifentanil with propofol or isoflurane. A comparison of the recovery times after arthroscopic surgery].
Due to its unique pharmacokinetics, the new esterase-metabolised opioid remifentanil results in rapid post-anesthesia recovery. The aim of this clinical investigation was to compare recovery times after remifentanil anaesthesia in combination with hypnotic concentrations of either propofol or isoflurane. Dosages used in the study protocol were based on recommendations by the pharmaceutical manufacturer. ⋯ Using the manufacturer's recommended dosages, emergence after remifentanil anaesthesia is more rapid with 0.5 MAC isoflurane than with 0.1 mg/kg/min propofol. These results are most probably due to the different pharmacological properties of both co-anaesthetics, especially the applied dosages, and to different interactions with remifentanil. Present clinical experience suggests that a further dose reduction, especially for propofol, is possible. For both remifentanil groups emergence was remarkably rapid between return of consciousness and the awake state (on-off phenomenon), which might contribute to post-anaesthesia safety.
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In more than 30 years of development of intensive care medicine (ICM), our specialty has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have been formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. ⋯ From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.
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Randomized Controlled Trial Clinical Trial Controlled Clinical Trial
[Low-flow anesthesia with desflurane].
Due to its low solubility and negligible metabolism, desflurane is assumed to be especially suitable for application by low-flow anaesthetic techniques. The aim of this clinical investigation was the development of a standardised dosing scheme for low-flow and minimal-flow desflurane anaesthesia. ⋯ The pharmacokinetic properties of desflurane, resulting in especially low individual uptake, and the wide output range of the vaporizer facilitate the use of low-flow anesthetic techniques in routine clinical practice. Even in minimal-flow anesthesia, the duration of the initial high-flow phase can be shortened to min. If the flow is reduced to 1 l/min, the inspired desflurane concentration achieved in the initial high-flow phase can be maintained without any alteration of the vaporizer setting. In minimal-flow anesthesia, however, with flow reduction to 0.5 l/min, the fresh gas concentration has to be increased to a value 1%-2% higher than the inspired nominal value. Due to the wide dialing range of the desflurane vaporizer, the amount of vapour delivered into the breathing system can be increased to about 110 ml/min even at a flow of 0.5 l/min. The large amount of agent that can be delivered into the system even under low-flow conditions, together with the very low individual uptake, results in a time-constant that is sufficient short for the clinically required rapid increase in inspired desflurane concentrations. The short time-constant of low-flow desflurane anaesthesia improves the control of the anaesthetic concentration. If all measures are taken to safely avoid inadvertent drying out of the soda lime, there is no evidence that low-flow anaesthesia with desflurane is liable to increase the risk of accidental carbon monoxide poisoning. (ABSTRACT TRUNCATED)