Der Anaesthesist
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Transoral laser surgery has become a standard procedure in the treatment of benign and malignant neoplasms of the upper aerodigestive tract. As the laser cuts and coagulates simultaneously, intraoperative bleeding is reduced, thus improving visualization of the operative field. ⋯ Although potentially fatal complications are rare, surgeon and anesthesiologist need to be aware of the dangers at all times and have exact knowledge of emergency measures. The use of suitable laser-resistant endotracheal tubes, total intravenous anesthesia and an optimized breathing gas mixture can contribute to minimize the occurrence of complications in otorhinolaryngology laser surgery.
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The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions. ⋯ A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.
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Comparative Study Observational Study
[Methohexital for analgosedation of ventilated intensive care patients : Prospective nonrandomized single center observational study on incidence of delirium.]
Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80 % of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium. ⋯ Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50 % in ventilated ICU patients.
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Restoration of adequate tissue perfusion is the goal of resuscitation in septic shock. A growing understanding of microcirculatory dysfunction in sepsis led to a change in resuscitation practice away from targeting arterial and central venous pressures and towards tissue perfusion-guided protocols. ⋯ Based on the published study results vasopressin appears to be of potential benefit in adult patients with moderate septic shock (norepinephrine requirements < 15 μg/min) and lacking signs of systemic hypoperfusion (e.g. normal arterial lactate levels). A vasopressin infusion with the sole target to increase arterial blood pressure despite the presence of systemic hypoperfusion is dangerous and can result in a critical deterioration of tissue perfusion.
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Sudden death due to cardiac arrest represents one of the greatest challenges facing modern medicine, not only because of the massive number of cases involved but also because of its tremendous social and economic impact. For many years, the magic figure of 1 per 1000 inhabitants per year was generally accepted as an estimate of the annual incidence of sudden death in the industrialized world, with a survival rate of 6 %. This estimate was based on large numbers of published reports of local, regional, national and multinational experience in the management of cardiac arrest. ⋯ In addition, important scientific questions can be answered from the database. For example, a score for benchmarking the outcome quality after out-of-hospital resuscitation, known as the return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score, has been developed. The registry is available for all emergency medical services (EMS) and hospitals in Germany and other German-speaking countries.