Der Anaesthesist
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Acute upper gastrointestinal bleeding in ICU patients has many possible causes: ulcer, adverse drug effects, gastric tube lesion, acute renal or liver failure, or stress-induced gastric mucosal lesion. Stress-induced gastric mucosal lesions typically are multiple superficial erosions, while ulcerations typically occur in patients with head trauma, neurosurgical operation or severe burns. Head trauma and neurosurgical patients are the only ones with increases gastric acid secretion; in general reduced acid secretion can be observed in ICU patients. ⋯ Active acid secretion depends on sufficient oxygen supply and mucosal ATP content. Hypotension and shock results in gastric mucosal ischaemia. These are the most important risk factors of stress bleeding.
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Review Randomized Controlled Trial Clinical Trial
[Medical therapy for coronary heart disease. Perioperative relevance].
The aim of our review is to summarize relevant data on the perioperative use of anti-ischaemic drugs in patients at risk for or with proven coronary heart disease. ⋯ Beta-blockers, calcium channel blockers, nitrates, and possibly alpha 2-agonists lead to reduced rates of PMI and other cardiac complications in risk patients. Current anti-anginal medications, with the exception of anti-platelet agents, should be maintained to the day of surgery and continued as soon as possible thereafter. All of these drugs except anti-platelet agents may also be used intra-operatively, however, possible interactions with anaesthetic agents should be carefully considered.
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The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. ⋯ Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.
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Review
[Pharmacology and clinical results with peridural and intrathecal administration of ketamine].
The epidural and intrathecal administration of opioids has gained wide acceptance among anaesthesiologists during recent years. Ketamine, an anaesthetic agent with an unusual pharmacological profile, has also attracted some interest in this context, as in subanaesthetic doses it provides marked analgesia without inducing respiratory depression. Since the first publication on the epidural administration of ketamine in humans in 1982, various studies on the pharmacology, toxicology and clinical use of ketamine by the epidural and intrathecal routes have been published. ⋯ Unfortunately, all commercially available ketamine preparations contain disinfectant agents whose intrathecal administration is prohibited. Epidurally administered ketamine doses of 30 mg and more seem to provide adequate postoperative analgesia, while smaller doses might be effective in chronic pain syndromes. More studies investigating the neurotoxicity and clinical effects of ketamine on the spinal cord are needed before wider use of the substance by this route of administration can be recommended.
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Knowledge of normal and impaired pulmonary gas exchange is essential to the anaesthesiologist. Analysis of an arterial blood sample allows evaluation of whether or not pulmonary gas exchange is normal. For this purpose comparison with the oxygenation index or the alveolar-arterial PO2 difference is helpful. ⋯ In daily practice, venous admixture or intrapulmonary shunt can be calculated using arterial and mixed-venous blood. By analysing arterial and expired PCO2, dead-space ventilation can be determined, but extended analyses of VA/Q distribution are not possible in daily practice. However, knowledge of the principles of typical disturbances of pulmonary gas exchange in acute and chronic lung disease allows the use of therapeutic strategies based on the pathophysiological changes.