Der Anaesthesist
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Case Reports
[Septic shock due to vancomycin-resistant enterococci infection. Tigecycline monotherapy].
Adequate antimicrobial therapy is of crucial importance for the survival of critically ill patients with severe nosocomial infections. Tigecycline is an important therapeutic option for the treatment of infections caused by multi-resistant Gram-positive and Gram-negative bacteria including vancomycin-resistant enterococci (VRE). A large randomised study (patients with APACHE-II-score >30 excluded/mean APACHE-II-score 6) demonstrated that tigecycline is not inferior to imipenem/cilastatin for treatment of complicated intra-abdominal infections. ⋯ As the site of anastomotic leakage was very small and could not be exactly identified, irrigation-suction drains were placed followed by closed postoperative continuous lavage. The pathogen responsible was identified as a vancomycin-resistant Enterococcus faecium, therefore monotherapy with tigecycline was started which resulted in microbiological response and clinical cure. Tigecycline is a new therapeutic option for the treatment of intra-abdominal infections and from an economic point of view financially rewarding when used as monotherapy.
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Randomized Controlled Trial Multicenter Study
[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study].
While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. ⋯ The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.
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Laryngeal and pharyngeal complaints are among the subjective problems most frequently reported by patients after general anaesthesia involving endotracheal intubation, others being pain, nausea and vomiting. Hoarseness, sore throat, and vocal cord injuries restrict patients' social lives, and in some cases also their working lives. ⋯ Knowledge of the pathophysiological aspects and other relevant factors associated with laryngopharyngeal morbidity are essential cornerstones of quality assurance in perioperative respiratory tract management. In this review specific sections are devoted to the implications of anaesthesia involving endotracheal intubation and laryngeal masks for laryngopharyngeal morbidity, and also particular aspects of thyroid gland surgery, cardiothoracic and bariatric surgery and obstetric and paediatric anaesthesia, and medicolegal aspects.
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Intramuscular injections of local anaesthetic agents regularly result in reversible muscle damage, with a dose-dependent extent of the lesions. All local anaesthetic agents that have been examined are myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury. The histological pattern and the time course of skeletal muscle injury appear relatively uniform: hypercontracted myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic reticulum myocyte edema and necrosis. ⋯ Increased intracellular Ca(2+) levels are suggested to be the most important element in myocyte injury, since denervation, inhibition of sarcolemmal Na(+) channels and direct toxic effects on myofibrils have been excluded as sites of action. Although experimental myotoxic effects are impressively intense and reproducible, only few case reports of myotoxic complications in patients after local anaesthetic administration have been published. In particular, the occurrence of clinically relevant myopathy and myonecrosis has been described after continuous peripheral blockades, infiltration of wound margins, trigger point injections, peribulbar and retrobulbar blocks.
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After neurosurgery patients often need to be sedated and ventilated in the intensive care unit (ICU). However, rapid postoperative recovery and neurological examination are particularly important for the early recognition of complications. In this retrospective study two different strategies of anaesthesia technique and ICU sedation (fentanyl-midazolam versus remifentanil-propofol) were compared. ⋯ This retrospective study demonstrates that remifentanil-propofol anaesthesia and ICU sedation are superior to the combination of fentanyl and midazolam in terms of ventilation time and length of ICU stay. Moreover, the use of fentanyl-midazolam may lead to unnecessary CT scans.