Der Anaesthesist
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23% of all septic patients develop septic encephalopathy which is associated with an increased mortality rate. Symptoms such as agitation, confusion and disorientation ranging from stupor to coma often develop in early sepsis. Severe hypotension is significantly associated with the development of septic encephalopathy. ⋯ The primary therapeutic goal is to maintain an adequate perfusion pressure and to prevent hypoxia and hypocapnia. Although the infusion of branched chain amino acids is controversial, experimental investigations demonstrated improvements improvements in an animal model with septic encephalopathy. Further investigations with respect to glutamate receptor antagonists, new radical scavengers, NO- and PARS-inhibitors may show whether these substances are suitable for the prophylaxis or early therapy of septic encephalopathy.
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Malignant hyperthermia (MH) is a genetic, potentially life-threatening disorder of the skeletal muscle presenting during or following general anaesthesia. Trigger agents are volatile anaesthetics and depolarising muscle relaxants. Dantrolene is the only available drug for effective and specific MH therapy, which reduces significantly the mortality rate. ⋯ In addition to its use for MH, dantrolene is used in other disorders such as neuroleptic malignant syndrome and spasticity. Since dantrolene is weakly water soluble, the clinical preparation is time and manpower consuming. New agents have been synthesized, but because of economic considerations no registration for clinical usage has been realised.
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Different therapeutic approaches have recently been developed for treatment of acute respiratory distress syndrome (ARDS) with the aim of improving the outcome. The clinical significance and success of these therapies is variable with respect to evidence based medicine. Lung protective ventilation is accepted as a proven therapy and the use of positive end-expiratory pressure as well as spontaneous breathing during controlled ventilation are common therapies. ⋯ The prone position is recommended for severe cases of ARDS and the application of inhaled nitric oxide and of extracorporeal membrane oxygenation is established in specialized centers for patients with imminent hypoxia. But for the routine use of these three therapies a clear improvement in outcome could not demonstrated. Recommended drug therapy is limited to the administration of stress doses of corticosteroids and a special anti-inflammatory enteral diet.
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In recent years point-of-care testing (POCT) has seen wider applications in the clinical management of surgical and critically ill patients. The available methods for haemostasis analysis include simple-to-handle tests for the assessment of plasmatic coagulation, platelet function tests and the more complex visco-elastic assays. The main advantage of POCT is the fast availability of the results allowing a targeted management of haemostasis disorders. ⋯ An underestimated aspect of POCT is the importance of established quality management procedures. For this purpose control materials based on plasma or artificial fluids are being applied. In spite of often higher costs we appraise the use of POC analysis in many settings as justified because of the gain of time and the overall better process quality, i.e. targeted haemostasis therapy instead of consecutive application of different therapeutic options.