Der Anaesthesist
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Selective digestive tract decontamination (SDD) is a method where topical non-absorbable antibiotics are applied to the oropharynx and stomach which primarily is aimed at the prevention of ventilator-associated pneumonia. The rationale for SDD is that ventilator associated pneumonia usually originates from the patients'own oropharyngeal microflora. SDD is also used for the prevention of gut-derived infections in acute necrotizing pancreatitis and in liver transplantation. ⋯ However, the most important drawback of SDD is the development of resistance and an increased selection pressure towards Gram-positive pathogens, especially in institutions with endemic multi-resistant microorganisms. Thus, it appears that "selective" must not only be interpreted as selective suppression of pathogenic bacteria but rather as selection of appropriate groups of patients with respect to underlying diseases and severity of illness. Furthermore, it means selection of ICUs where the endemic resistance patterns might allow the use of SDD at a relatively low risk for selection of resistant microorganisms, which is still the major concern associated with SDD.
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In long-term treatment opioids seem to have only minimal side-effects compared with other analgesics and co-analgesics. Nevertheless, some risks have to be considered. While immunosuppression, neurotoxicity, teratogenity, tolerance and addiction are clinically not relevant or very rare, cognitive impairment, sedation and obstipation may have a clinical impact. ⋯ For clinical practice of long-term opioid therapy in non-malignant pain a specialized knowledge in pain management is a prerequisite. Future studies with more sophisticated methodology will be necessary to advocate more precise guidelines. However, the therapeutic recommendations from the DGSS consensus conference allow a safer,well structured and validated use of opioids for chronic non-malignant pain.
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Caudal anaesthesia is the most frequently used regional technique in paediatric anaesthesia. Caudal in combination with general anaesthesia is usually performed in healthy children (i.e. for herniotomy or hypospadias). Therefore every complication of this method is a catastrophe, even when the incidence of these complications is very low. ⋯ In addition, levobupivacaine, the L-enantiomere of bupivacaine, will also be an interesting local anaesthetic in the future for paediatric caudal anaesthesia. By using additives to local anaesthetics better analgesic properties should be obtained. Following an exact review of the literature, only clonidine and S(+)-ketamine are useful additives to local anaesthetics in paediatric caudal anaesthesia.
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Sepsis and septic shock are the leading causes of death in non-cardiological intensive care units in developed countries despite recent advances in critical care medicine. Sepsis is the systemic inflammatory response to infection, often associated with hypoperfusion followed by tissue injury and organ failure. Activation of monocytes/macrophages and neutrophils with consecutive release of proinflammatory mediators and activation of the coagulation cascade, seem to play a key role in the pathogenesis of sepsis. ⋯ In contrast,now two new promising treatment options may be emerging: application of small doses hydrocortisone and activated protein C [drotrecogin alfa (activated)]. Large and in part multicentric studies especially in the last 2 years now allow the practicing clinician to perform a partially evidence-based management of patients with sepsis. In addition, for the first time two options for specific therapy of sepsis,application of small doses hydrocortisone and activated protein C [drotrecogin alfa (activated)],are available which may further improve prognosis for septic patients.
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Review
[Ultrasound in local anaesthesia. Part II: ultrasound-guided blockade of peripheral nerve channels].
Recent developments in blockade techniques are based on the possibilities offered by modern sonography. With high frequency linear probes, the smallest tissue structures, such as peripheral nerves, in areas close to the surface can be visualised. ⋯ Apart from these, one particularly important aspect is that they reduce the risks of local anaesthesia procedures by direct imaging of neighbouring anatomical structures. In this article the theoretical basis of ultrasound techniques and their practical use in local anaesthesia will be presented.