Der Anaesthesist
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The function of the brain is not checkable in comatose or sedated patients. Because secondary brain damage will often cause brain edema it is necessary to recognize the resulting increases in brain pressure. Therefore, measurement of intracranial brain pressure (ICP) is the standard monitoring procedure in neurological intensive care. ⋯ Other neuro-monitoring procedures have not achieved the value of ICP measurement and only reflect changes in ICP with other measurement principles. ICP measurement is the procedure which is decisive for conservative measures in the intensive care unit to secure cerebral perfusion or indications for surgical treatment of brain edema. Central venous pressure, intra-abdominal pressure and positive end-expiratory pressure do not have a substantial influence on ICP.
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In the last decade prehospital focused abdominal sonography for trauma (P-FAST) could be established as a valid on-site diagnostic tool for both air and ground rescue medical services in Germany. An appropriate use of P-FAST demands a standardized training concept. Therefore a 1-day training program was developed by the working group "emergency ultrasound" in Frankfurt/Main and was introduced in 2003. ⋯ After completing the P-FAST course the participants gained competency to perform prehospital emergency ultrasound with high accuracy. Strict application of the exact technique as well as appropriate integration of the adjunct into the algorithm of prehospital care are the most important prerequisites for successful use of P-FAST. From February 2003 to March 2008 540 participants were trained in P-FAST in the 1-day course.
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The share of ambulatory procedures is increasing with advances in operative and anesthesiological methods and pressured by economical necessities. Following legal regulations procedures with and without hospital stay underlie the same quality measures. Multimodal concepts comprising anesthesiological and operative procedures, pain therapy as well as postoperative care allow for quality improvements in respect to operative outcome and patient satisfaction.
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Basic therapy of acute lung injury (ALI) covers a pressure-limited lung protective mechanical ventilation with low tidal volumes (6-8 ml/kg ideal body weight), adequate positive end-expiratory pressure (PEEP) combined with early recruitment maneuvers and a restrictive fluid management (in hypoproteinemic patients preferably with albumin and diuretics). These measures aim at providing sufficient oxygenation while simultaneously minimizing airway pressure, atelectasis and edema formation. The main hemodynamic effects are a decrease in cardiac output and in systemic arterial pressure potentially reducing organ perfusion. However, successful therapy reduces hypoxic pulmonary vasoconstriction and hypercapnia, thus lowering pulmonary artery pressure, unloading the right ventricle, and stabilising hemodynamics.
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Proinflammatory mediators as well as increased formation of reactive oxygen and nitrogen species impair cellular respiration during sepsis. In particular, the highly reactive peroxynitrite irreversibly damages lipids, proteins and nucleic acids and also inhibits enzyme complexes of the respiratory chain. ⋯ Repair of DNA by poly(ADP-ribose)polymerase consumes large amounts of nicotinamide adenine dinucleotide (NAD+) which leads to cellular NAD+ depletion further promoting inflammation. This article summarizes central aspects of the pathophysiology of mitochondrial dysfunction during sepsis and gives an overview about newly developed strategies which proved effective in experimental studies and may have a potential clinical application in the future.