Der Anaesthesist
-
Molecular biology has revolutionized medicine by increasing our understanding of the pathophysiological mechanisms of disease and the ability to assess genetic risk. Individual differences in disease manifestation and course in intensive care medicine often cannot be explained by known phenotypic risk factors alone. ⋯ TNF-alpha, Il-10), infectious diseases such as pneumonia or meningitis, sepsis, ARDS, as well as the mortality of critically injured patients (polytrauma, severe brain trauma). Continued identification of such allotypes and haplotypes may not only provide insight as to why the response to treatment varies amongst individuals in the intensive care unit, but also may potentially decrease morbidity and mortality through improved risk assessment and the administration of prophylactic therapy.
-
The process of evidence-based medicine incorporates structured clinical problem solving aimed at providing an optimal, patient-centred therapeutic approach. Evidence-based medicine is supported by justified therapeutic principles rather than physicians' intuition only. Few of the published articles allow firm conclusions for a rational patient approach. ⋯ Besides the careful analysis of source data, evidence-based medicine warrants the final evaluation of outcomes for process improvement. This can be obtained utilising surrogate parameters, such as organ failure, resource allocation, or quality of life, or crude mortality of the patients. The integration of personal know-how together with sufficient knowledge and critical appraisal of the current literature may finally lead to improved outcomes.
-
The pharmacokinetics of opioids are impaired in patients with liver and renal failure. Fentanyl, sufentanil, and alfentanil are metabolized in the liver. The extrahepatic metabolism by renal enzymes is gaining more importance in patients with severe liver disease. ⋯ The clearance of morphine is reduced in liver failure. In renal failure an accumulation of morphine metabolites has been demonstrated, and thus, application of morphine is not recommended in patients with liver and renal failure. A reduction in piritramide dosing is necessary in patients with liver failure.
-
Despite the low incidence of the acute porphyrias, a profound knowledge of the disease is essential for anaesthesiologists, as a variety of perioperatively administered drugs are potential triggers of an acute attack. There is an ongoing discussion about the use of volatile anaesthetics in porphyrias, but halothane and isoflurane seem to be safe. There is no clinical data or case report about the use of desflurane in this specific patient group, but its fast and relatively unchanged elimination and the minimal induction of the cytochrome P 450 system seem to be favorable in this setting. ⋯ The patient was discharged on postoperative day 21 in excellent condition. We conclude that our perioperative management prevented an acute porphyric attack in this case. Desflurane might be a valuable alternative to other hypnotics in patients with AIP.
-
Mortality rates remain high for the acute respiratory distress syndrome (ARDS) despite standardised treatment algorithms. Little is known about prognostic factors and exclusion criteria for advanced treatment including extracorporeal membrane oxygenation (ECMO). ⋯ Advanced treatment of ARDS including ECMO represents a therapeutic option if none of the currently considered contraindications are present. An improvement in gas exchange parameters, but not a defined value per se may be useful as a prognostic factor for favourable outcome.