Der Anaesthesist
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With an incidence of 130,000 per year, sudden cardiac death is one of the most frequent causes of death in Germany. Each day 350 patients die from cardiac arrest. Survival depends essentially on the time delay before professional help arrives and sufficient resuscitation measures have been started. ⋯ Even in large hospitals with maximum care facilities, delays before beginning resuscitation measures can occur which results in a dramatic reduction of the survival rate. Therefore, it seems reasonable to use AED in large hospitals. For implementation, training programmes and a nationally standardized documentation of resuscitation events should be promoted.
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Disturbances of some partial liver functions, such as synthesis, excretion, or biotransformation of xenobiotics, are important for prognosis and ultimate survival in patients presenting with multiple organ dysfunction on the intesive care unit (ICU). The incidence of liver dysfunction is underestimated when traditional "static" measures such as serum-transaminases or bilirubin as opposed to "dynamic" tests, such as clearance tests, are used to diagnose liver dysfunction. Similar to the central role of the failing liver in MODS, extrahepatic complications, such as hepatorenal syndrome and brain edema develop in acute or fulminant hepatic failure and determine the prognosis of the patient. ⋯ In addition to specific and causal therapeutic interventions, e.g. N-acetylcysteine for paracetamol poisoning or termination of pregnancy for the HELLP-syndrome, new therapeutic measures, e.g. terlipressin/albumin or albumin dialysis are likely to improve the poor prognosis of acute-on-chronic liver failure. Nevertheless, liver transplantation remains the treatment of choice for fulminant hepatic failure when the expected survival is <20%.
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Intraoperative wakefulness ("awareness") is still a relevant problem. Different stages of wakefulness exist: conscious awareness with explicit recall of pain in 0.03% and with nonpainful explicit recall in 0.1-0.2% of all anesthesias; amnesic awareness or implicit recall may occur with unknown, even higher incidences. Sufficient analgesia minimizes possible painful perceptions. ⋯ The observation of clinical signs does not reliably detect intraoperative wakefulness in all cases; monitoring of end-tidal gas concentrations, EEG, or evoked potentials may help in prevention. Active information is recommended only for patients at higher risk. Complaints about recall of intraoperative events should be taken seriously; in cases of sustained symptoms psychological help may be necessary.
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Oxygenation and ventilation as well as prevention of aspiration are of vital importance for emergency patients. Prehospital airway management is not comparable to clinical anaesthesia. However, prehospital data of the occurrence of potential life-threatening complications and less severe adverse events of airway management procedures by emergency physicians are not yet available. ⋯ Prehospital airway management by emergency physicians experienced in anaesthesia is associated with low complication and high success rates.
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Extensive knowledge and skills in the basics of emergency medical care are of paramount importance for every physician and should therefore be an integral part of medical education. ⋯ The extremely positive evaluation of the new approach encouraged us to promote AIX-PERT further. In the future the effects of success of this approach will be assessed by longitudinal studies of skills and knowledge during the continuing curriculum.