Der Anaesthesist
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Contrary to the situation in "classical" clinical pharmacology, non-steady state phenomena play a fundamental role for clinical pharmacology in anesthesia. Their understanding is of tantamount importance for the safe and efficient application of drugs relevant to anesthesia. Concepts like optimised target-controlled infusion (TCI), effect compartment targeting and the small margin of error tolerable during maintained spontaneous ventilation, force the anesthesiologist to acquire a firm understanding of the difference between the concentration time course at the effect side vs. time course of the plasma concentration. The underlying concepts, their application for the rational use of muscle relaxants, propofol with TCI systems, volatile anaesthetics and opioids will be discussed.
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Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. ⋯ To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.
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The expected cost-explosion in transfusion medicine (increasing imbalance between donors and recipients, treatment of transfusion-associated complications) increases the socio-economic significance of the development of safe and effective synthetic oxygen carriers as an alternative to the transfusion of allogeneic red blood cells. Currently two types of artificial oxygen carriers have been tested for safety and efficacy in cases of severe anemia otherwise requiring transfusion. Solutions based on human or bovine hemoglobin (HBOC) possess vasoconstrictor properties in addition to their oxygen transport capacity. ⋯ Due to their particulate nature (emulsion droplets) PFCs may only be infused in low doses to avoid overload and malfunction of phagocytic cells of the reticulo-endothelial system. As part of a multimodal blood conservation program (including normovolemic hemodilution and hyperoxia) the low-dose administration of Oxygent effectively increases intraoperative anemia tolerance. Although reduction of perioperative allogeneic blood transfusion has already been demonstrated for HBOC and PFC, the global clinical establishment of artificial oxygen carriers is not to be expected in the near future.
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Management means developing, shaping and controlling of complex, productive and social systems. Therefore, operating room managers also need to develop basic skills in financial and managerial accounting as a basis for operative and strategic controlling which is an essential part of their work. ⋯ Since hospitals need to implement a strategy to reach their business objectives, the performance measurement system has to be individually adapted to the strategy of the hospital. In this respect the navigation system developed by Gälweiler is compared to the "balanced score card" system of Kaplan and Norton.
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In parallel with Austria's entry into the European Union, the examination system for both general practitioners and specialists at the end of their training was changed from voluntary to mandatory. Subsequent changes in laws and directives in Austria constituted the basis for the development of specific examination guidelines for each medical sub-specialty. ⋯ Because of transitional regulations the actual number of candidates for the oral examination currently lies way below the expected number of 80-100. The decision to demand positive performance in the part 1 examination for the European Diploma of Anaesthesiology has, however, already proven that this type of combined examination system is of a high standard and will produce properly qualified specialists in anaesthesiology.