Der Anaesthesist
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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.
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Fluid optimization is a major contributor to improved outcome in patients. Unfortunately, anesthesiologists are often in doubt whether an additional fluid bolus will improve the hemodynamics of the patient or not as excess fluid may even jeopardize the condition. ⋯ The dPP cutoff value of 13% to predict fluid responsiveness is presented together with several assessment techniques of dPP. Finally, confounding variables on dPP measurements, such as ventilation parameters, pneumoperitoneum and use of norepinephrine are also mentioned.
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Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. ⋯ Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.
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Critically ill patients with severe systemic inflammation can develop critical illness-related corticosteroid insufficiency (CIRCI), which is associated with a poor outcome. A task force of the American College of Critical Care Medicine compiled recommendations for diagnosis and treatment of this clinical entity thereby focusing on patients with septic shock and acute respiratory distress syndrome (ARDS). The results of large scale multi-centre trials gave partially conflicting results arguing against the broad use of corticosteroids in stress doses. ⋯ Preliminary data suggest that patients with vasodilatory shock after cardiac surgery and patients with liver cirrhosis and sepsis can benefit from corticosteroids. Critical illness-related corticosteroid insufficiency can also occur in patients with trauma, traumatic brain injury, acute pancreatitis and burn injuries, but data from clinical trials on these target groups are insufficient at present. The therapeutic use of corticosteroids in stress doses reduces the incidence of post-traumatic stress disorder (PTSD) after intensive care treatment.
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There is lack of studies investigating procedures aiming at a decrease in perioperative mortality in patients with obstructive sleep apnoea (OSA). During anesthetic evaluation, identification of patients with OSA as well as using a risk score has been recommended by the American Society of Anesthesiology in order to identify the best perioperative strategy. ⋯ Continuous pulse oximetry should be used as long as patients remain at increased risk and should be applied until oxygen saturation remains above 90% with room air during sleep. Opioids should be excluded for pain management whenever possible, and CPAP or NIPPV should be administered as soon as feasible after surgery to patients who have been receiving it preoperatively.