Der Anaesthesist
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Drotrecogin alfa (activated) (DrotAA) represents a therapeutic advance in the treatment of severe sepsis. In the pivotal PROWESS trial DrotAA had demonstrated a significant decrease in 28-day mortality, most evident in the subgroup of patients at higher risk of death. Thus, DrotAA was licensed throughout Europe for treatment of adult patients with severe sepsis with multiple organ failure when added to best standard care. ⋯ The ENHANCE open-label trial enrolled similar patients to the PROWESS trial and the observed 28-day mortality was consistent with the results seen in the PROWESS trial. Survival rates for patients receiving DrotAA early within 24 h from the first sepsis-induced organ dysfunction were significantly higher than in patients treated later. In this overview we will discuss the results of the ENHANCE and ADDRESS trials in the context of the PROWESS study and clinical implications for the treatment with DrotAA.
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Drotrecogin alpha (recombinant human activated protein C, rhAPC; Xigris) is an immune modulating treatment principle that has been shown to significantly reduce mortality in patients with severe sepsis. Currently, the identification of patients in intensive care that may benefit from such a treatment is insufficient. The importance of this evidence-based treatment modality is commonly ignored for reasons of increased cost. ⋯ This may benefit patients with severe sepsis of not longer than 48 h duration, an APACHE II score of > or =25 or > or =2 failing organs and no exclusion criteria. Extending the indication beyond this group should be discussed as a last resort in patients with a fulminant clinical course, such as in meningitis, and based on data from retrospective subgroup analyses. Patients with severe sepsis following community-acquired pneumonia with progressive organ dysfunction may also benefit from activated protein C treatment in addition to an otherwise best standard of care.
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A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. ⋯ Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).
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The endovascular treatment of diseases of intracranial and spinal vessels has become widely accepted in recent years. The patient is usually treated under general anesthesia and in choosing an appropriate anesthesia regimen and an optimized pre-interventional preparation, the anesthesiologist can influence the postinterventional result. The working environment in the angiography suite should address the requirements of a routine procedure and the necessities of complication management. ⋯ After the procedure the patient has to be monitored for at least 24 h. Peri-interventional and postinterventional complications, such as thrombo-embolism or hemorrhage, must be managed aggressively and consequently by the anesthesist to improve the postinterventional outcome. Therefore a close collaboration between the anesthesiologist and the neuroradiologist is essential.
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Randomized Controlled Trial Comparative Study
[Pharmacodynamics of two different propofol formulations].
Propofol is nowadays available in various lipid formulations. We compared two different propofol formulations with respect to pharmacodynamics, using the EEG and clinical signs. ⋯ The investigated lipid formulations have no influence on the pharmacodynamics of propofol.