Der Anaesthesist
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Microcirculatory dysfunctions play a central role in the pathophysiology of sepsis and shock. Modern methods enable microvascular monitoring in man and offer the possibility to test the effect of novel therapeutical strategies for sepsis. Furthermore, these techniques may be future tools for the monitoring of critically ill patients. ⋯ Alterations in sublingual microvascular blood flow are detected by intravital microscopy in septic patients and were identified as an outcome predictor. Furthermore, the role of gastrointestinal pCO2-tonometry for microcirculatory monitoring of the perfusion of splanchnic organs during sepsis is discussed. The true clinical value of these techniques has yet to be established and will depend on larger clinical trials showing an impact on diagnostics and patient management.
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German hospitals face growing economic pressure. Due to the reimbursement system with diagnosis-related groups (DRGs), revenues from capitation fees have to be earned by each clinic. This leads to minimization of resources for every single case. ⋯ Focus is on cooperation in the operation room, advantages and risks of teamwork and auxiliary measures for improvement. The aim is to underline how complex and fragile working in an operation room proceeds and how little is done to support this process. Finally, examples are described which improve teamwork, motivation, efficiency and efficacy.
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Randomized Controlled Trial
[Clinical pathway "laparoscopic prostatectomy". Analysis of anesthesiological procedures in a randomized study].
In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure. ⋯ Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.
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Case Reports
[Accidental hypothermia in the household environment. Importance of preclinical temperature measurement].
In emergency medicine accidental hypothermia in non-traumatized patients is a rare situation. To emphasize the need for a precise preclinical temperature measurement, two cases of accidental hypothermia (28.2 degrees C and 29.3 degrees C core temperature) are presented which occurred under conditions that did not give a direct suspicion of hypothermia. In one case the immediate diagnosis lead to complete convalescence, the other patient died of multiple organ failure. The primary diagnosis, diagnostic methods and therapy as well as the primary treatment are discussed.
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Case Reports
[Negative pressure pulmonary edema. Post-obstructive lung edema after use of a laryngeal mask].
A 31-year-old male patient was scheduled for surgical treatment of a distal radius fracture under general anaesthesia using a laryngeal mask airway and spontaneous ventilation. The intraoperative course was uneventful. ⋯ A portable chest radiograph demonstrated bilateral alveolar infiltration suggesting pulmonary edema. The patient was transferred to the intensive care unit where drug therapy (furosemide and hydrocortisone) and treatment with the continuous flow continuous positive airway pressure (CF-CPAP) system led to complete recovery within 24 h.