Der Anaesthesist
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Medical performance is subject to quality control. Continuous advanced training (CAT) and continuous medical education (CME) are essential, and quality must be checked and assured: structure (contents, organizational form, framework, term, demands on teachers), process (term of the CAT, interaction between teachers and participants) and results (satisfaction and acceptance, increased knowledge, influence on medical treatment, improvement of the success rate of medical treatment. In emergency medicine one must differentiate between the necessity for CAT (e.g., certified proof required for working as an emergency physician) and a desire for CME (the individual task of the physician). ⋯ The influence of advanced training on further medical treatment can be seen in the quality of a given CAT/CME measure, but not in the success rate of medical treatment. The result desired can only be achieved by linking all system components of medical quality control and assurance. Advanced training provides a fundamental contribution to this end.
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GOAL OF THIS REVIEW: We review the recent literature and our experience in order to determine how one can recognize and handle patients with difficult endotracheal intubation.
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Review Comparative Study
[Nephrotoxicity and fluoride from the viewpoint of the nephrologist].
Fluoride released from methoxyflurane (MOF) during its hepatic and extrahepatic metabolism has been regarded as the major culprit responsible for MOF-induced nephrotoxicity. In the isolated, perfused rat kidney model, admixture of 1500 mumol/l fluoride to the perfusate resulted in tubular and glomerular damage with concomitant anuria. Fluoride administration in Fischer 344 rats in vivo elicited a renal diabetes insipidus-like syndrome that had also been observed in patients after MOF anaesthesia. ⋯ The degree of nephrotoxicity correlates loosely with maximal serum fluoride levels, but can probably be modulated by further factors like intrarenal in situ formation of fluoride, urinary pH and flow, and especially, the presence of other nephrotoxins. This mitigates the importance of maximal fluoride serum levels, especially the 50 mumol threshold, as predictors of clinically relevant nephrotoxicity. To date, no nephrotoxic effects of sevoflurane could be demonstrated.
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Midlatency auditory evoked potentials (MLAEP) are suppressed dose-dependently during anaesthesia with a variety of general anaesthetics. Therefore, MLAEP have been proposed to measure depth of anaesthesia and to indicate intraoperative awareness. Several studies give evidence of a close relationship between MLAEP and motor signs of wakefulness, intraoperative awareness, and explicit and implicit memory functions during general anaesthesia. ⋯ The new volatile anaesthetic sevoflurane leads to a dose-dependent increase in MLAEP peak latencies and a decrease in MLAEP amplitudes. At about 1.5 vol.% end-expiratory sevoflurane concentration, MLAEP are significantly suppressed and Nb latency is in the range of 68-80 ms. Therefore, from the present data and those from the literature, one may expect that sevoflurane at concentrations greater than 1.5 vol.% for general anaesthesia would be able to suppress awareness phenomena such as purposeful movements, auditory perception, intraoperative wakefulness and awareness, memory formation, and explicit and implicit recall of intraoperative events.
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Review Comparative Study
[Effects of sevoflurane on the area of the liver and spleen].
Recently, there has been increased interest in the preservation of hepatic function during anaesthesia and surgery. In common with other halogenated volatile anaesthetics, sevoflurane causes dose-related cardiovascular depression, which suggests that the blood flow of various organ systems is affected. ⋯ The effort should be encouraged to study this new volatile anaesthetic in human subjects; if a parallel to isoflurane can be drawn, the impact of both substances on the hepatic circulation should be quite small. In Germany, the introduction of sevoflurane into clinical practice should be a reason to proceed with clinical investigations of this type.