Der Anaesthesist
-
Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. ⋯ Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.
-
Review
[Ultrasound-guided peripheral regional anesthesia : placement and dosage of local anesthetics].
Ever since the use of ultrasound guidance in regional anesthesia became more and more popular in recent years, it seemed obvious that so-called intraneural puncture and injection of local anesthetics was much more common than previously assumed. However, neurologic damage was not seen very often. The ultrasound-guided imaging of the nerves showed that intraneural injection has to be seen as an overall term. ⋯ In studies investigating the minimal effective local anesthetic volume needed for successful nerve block, a relevant reduction of injected volume was still achieved by intentionally applying the local anesthetic circumferentially around the outermost nerve layer rather than injecting it into neural structures. As an intraneural -intrafascicular injection carries the risk of nerve injury associated with a decrease in quality of life, the potential of ultrasound guidance in regional anesthesia should be considered. Circumferential administration of local anesthetic rather than creating a single point injection appears to be advantageous.
-
The gastrointestinal tract is a complex organ system. Dysfunctions of this organ system may evoke a variety of consequences for the entire organism and influence the inflammatory response in particular. In perioperative medicine, nutrition, prokinetics, peridural anesthesia, catecholamines and volume therapy can be applied in order to improve the gastrointestinal functional or at least to avoid further aggravation. ⋯ Norepinephrine, if necessary in combination with dobutamine, seems to have fewer negative effects on splanchnic perfusion than epinephrine. The data on volume therapy remain controversial but fluid balance has to be calculated very carefully also considering enteral loss of fluids. Thus, in order to treat and avoid gastrointestinal problems after surgery and to prevent negative effects for the complete organism, multimodal concepts with regard to detail are required.
-
Regarding the question of an adequate depth of anesthesia, over the past decade anesthesiologists have focused on the prevention of intraoperative consciousness in combination with explicit memory. Recent studies approached the topic from a different way postulating that deep anesthesia, quantified as time with a bispectral index (BIS)< 45, is associated with increased postoperative mortality and four out of the five published studies revealed such a correlation. ⋯ An epiphenomenon implies e.g. that patients with cancer respond to general anesthesia with deeper cortical depression. In summary, as long as there is a lack of adequately performed randomized trials, there is no reason why anesthesiologists should change the current practice.