Der Anaesthesist
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In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.
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Randomized Controlled Trial
[Health-related quality of life after mechanical ventilation in the intensive care unit].
It is unknown whether health related quality of life measured in German patients one year after mechanical ventilation in the intensive care unit is impaired or not. ⋯ The EORTC QLQ-C30 questionnaire is suitable for the acquisition of the health-related quality of life in formerly critically ill patients. Health-related quality of life is severely impaired after mechanical ventilation in the intensive care unit. Future studies should consider health related quality of life as a possible study endpoint.
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The circle system has been in use for more than 100 years, whereas the first clinical application of an anaesthetic reflector was reported just 15 years ago. In the circle system, all breathing gas is rebreathed after carbon dioxide absorption. A reflector, on the other hand, with the breathing gas flowing to and fro, specifically retains the anaesthetic during expiration and resupplies it during the next inspiration. ⋯ But obviously, the outcome is most important. We know that deep intravenous sedation increases mortality, whereas inhalational sedation could prove beneficial. We now need prospective clinical trials examining mortality, but also the psychological outcome of those most critically ill patients sedated by inhalation or intravenously.
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Trauma-induced coagulopathy, one of the leading causes of trauma-related death, is detected in about one of four trauma patients upon hospital admission. The current European Management of Major Bleeding and Coagulopathy Following Trauma guidelines, published in 2013, recommend that tranexamic acid (TXA) be administered as early as possible to inhibit hyperfibrinolysis (grade of recommendation (GoR 1A)). Furthermore, it is suggested that protocols for the management of patients with bleeding or showing signs of bleeding include the administration of the first dose of TXA at the site of injury or during transportation to hospital (GoR 2C). There is no current data showing to what extent TXA is used in the pre-hospital settings in Germany. ⋯ The survey shows a widespread distribution of TXA in the German EMS, which has significantly increased between 2010 and 2015. However, nationwide distribution has not yet been established. This rise in distribution is interpreted as a reaction to national and European guidelines for the management of severe bleeding and trauma care. A remaining question is to determine which patients should be treated with TXA, as hyperfibrinolysis is not detectable at the site of injury.
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Perioperative care for patients undergoing carotid endarterectomy (CEA) often presents a challenge to the anesthesia provider, as this patient group commonly suffers from a wide range of comorbidities. Although clinical trials could not demonstrate a significant benefit associated with regional anesthesia for outcomes such as insult, cardiac infarction or mortality, many authors concur that regional anesthetic techniques might be preferential in specific patient populations for this type of surgery. ⋯ With regional anesthetic techniques evolving to be more and more complex, the use of ultrasound is becoming increasingly indispensable in the operating theatre. For anesthesiologists with sufficient training and a profound knowledge of the respective anatomy, regional anesthesia seems to be a veritable alternative to general anesthesia for CEA.