Der Anaesthesist
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The term "malignant hyperthermia" (MH), regarded as the typical anaesthetic disease, refers to a clinical syndrome of varying intensity (from abortive courses to fulminant crises) and develops only under exposure of certain triggering substances or mechanisms. MH is caused by a defect in the ryanodine receptor subtype 1, which can often be proved genetically. Furthermore, it may also be generated by other mechanisms which disturb the membranous integrity of skeletal muscle cells (e.g. some myotonias, muscular dystrophies, malformation syndromes). ⋯ Due to a current good knowledge about classical triggers, symptoms and therapeutic interventions, a clinical MH presentation may successfully be treated in the perioperative period. However, it appears to be likely that there are unreported cases outside hospitals since atypical courses or alternative MH triggers (e.g. alcohol, drugs, physical stress) may impair the correct diagnosis. In contrast severe hyperthermia can also arise from other drug-induced diseases, e.g. the neuroleptic malignant syndrome or the serotonin syndrome.
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After 30 years of belt-tightening in the health care system and the mandatory implementation of the German diagnosis-related groups (DRG) system in 2004, the cost pressure on German hospitals has increased again. Cases break even only if prime costs fall below DRG revenues. On the one hand it is required from hospitals that prime costs are evaluated in terms of effectiveness, but on the other hand they have to allow for generation of adequate revenues and performance-oriented distribution of profits. ⋯ Aspects in the field of anaesthesia which are relevant to the generation of adequate revenues are: documentation of intraoperatively occurring diagnoses, documentation of intraoperative procedures, the grouper function "complicating procedure", the demographic attribute "hours on mechanical ventilation" and the issue of supplemental revenues. Following comments on the generation of adequate revenues, the alternative means of internal budgeting, the German DRG case-costing and the percentage of sales method, are discussed. The present contribution is intended to assist readers in the prevailing discussion about economic awareness of the health care market.
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The constancy of body temperature (CBT) is a cornerstone of homeostatic, homothermic organisms and is essential for a regulated course of biochemical and biophysical reactions. Severe deviations from normothermia (36.8+/-0.4 degrees C) are life threatening and even a moderate perioperative reduction of the CBT is coupled with an increased morbidity and mortality especially in high-risk patients. The relevant factors are coagulation disturbances, increased infection rate and increased cardiac risk. ⋯ On the other hand, a deliberate reduction in temperature or induced hypothermia is a neuroprotective procedure, which offers a therapeutic option to minimize neuronal secondary damage after primary hypoxic-ischemic events as well as extending the neuronal tolerance to ischemia. Management includes the practice of cooling down to a defined temperature, rewarming as well as a differentiated control of various parameters. Furthermore, side-effects which increase in severity with decreasing temperature must be taken into consideration.
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Experimental studies have demonstrated the neuroprotective effects of induced hypothermia in prevention of secondary insults following acute brain injury. Therefore, therapeutic hypothermia could be effective in the clinical setting of intensive care therapy. In this paper pathophysiological aspects of induced hypothermia are discussed and clinically relevant study results of hypothermia therapy are given in respect to evidence-based medicine.
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Review
[Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx].
Accurate perioperative fluid balance is the basis of a targeted infusion regimen. However, neither the initial status nor perioperative changes of the fluid compartments can be reliably measured in daily routine. In particular, insensible losses are not consistently assessed, so that substitution therapy is generally empirical. ⋯ An inconstant fluid and protein shift towards the interstitial space perioperatively seems to be associated with hypervolemia, which suggests it should be preventable. The decisive factor in this context seems to be deterioration of the endothelial glycocalyx, whose further patho-physiological impact is currently only partially known. Clinical studies have revealed a link between fluid restriction and improved outcome after major abdominal surgery.