Der Anaesthesist
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The innate immune system succeeds against the majority of infections before the adaptive immune system is activated. New findings contribute to a better understanding of the pathophysiology of sepsis and lead to the development of new therapeutic strategies. The innate immune system, being responsible for the first response to infections, can trigger adaptive immune responses in case the initial response is ineffective. ⋯ The environment in sepsis can cause disseminated intravascular coagulation (DIC), but at the same time thrombin triggers the release of chemokines and adhesion molecules through endothelial cells, which represents a positive feedback mechanism for innate immune responses. New therapeutic strategies for sepsis try to establish a well-balanced immune response. Intervention is accomplished through inhibition of inflammatory cytokines, their receptors or through activation of immunostimulatory responses.
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From a pharmacological perspective, anesthesia is concerned with controlling the time course of drug effect. Mathematical models are commonly used to relate the administered drug dose to the measured drug concentration (a pharmacokinetic model) and to relate the measured drug concentrations to the measured drug effects (a pharmacodynamic model). With such models, the time course of the drug effect for different drug regimens can be predicted. ⋯ An understanding of the "effect compartment concept" and the "time of the peak effect site concentration," together with the concepts of" context sensitive"half-time and "relevant decrement time,' contribute substantially to the anesthetist's understanding of the principles governing the onset and offset of drug effect. As part of a computer-controlled infusion system, the pharmacokinetic model facilitates optimized and rational dosing. These systems, also called target-controlled infusion systems (TCI), calculate the infusion rates for rapidly achieving and then maintaining a target concentration.
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Clinical Trial
[Bispectral index and desflurane concentration below 1 MAC].
We investigated the relationship between bispectral index (BIS, A-2000, Aspect Medical Systems, USA) and end-tidal desflurane concentrations below 1 MAC which is especially the range of interest if desflurane is combined with remifentanil for fast-track anaesthesia. ⋯ We could demonstrate a relationship between bispectral index and end-tidal desflurane concentrations below 1 MAC with a BIS range of 49-40 being associated with approximately 0.5 MAC of desflurane during desflurane-remifentanil-anaesthesia.
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Principles and characteristics of the recently introduced Microcuff paediatric tracheal tube (Microcuff, GmbH, Weinheim, Germany) with anatomically based depth markings, cuff-free subglottic tube shaft and short high volume-low pressure cuff with ultrathin cuff membrane are presented. First available tubes (ID 4.0 mm) were evaluated regarding cuff pressures required to seal the trachea and regarding the distance from the tube tip to the carina. ⋯ The new Microcuff paediatric tracheal tube with ultrathin high volume-low pressure cuff required tracheal sealing pressures below tracheal wall pressures usually required with uncuffed tracheal tubes for efficient sealing and ventilation at 20 cm H(2)O peak inspiratory pressure. The distance from the tube tip to carina was in the safe range in all patients.
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Sepsis is still a leading cause of death in many intensive care patients. The pathophysiology of the disease is dominated by complex immune cascades. Recent research demonstrates that immune cells respond to sepsis with an increased rate of programmed cell death. ⋯ Overexpression of Bcl-2 or inhibition of caspases resulted in an increased survival in animal models of sepsis. Recent reports indicate the relevance of apoptosis in patients with severe sepsis. These results may spawn novel immunomodulatory strategies in the treatment of sepsis.