Der Anaesthesist
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Hemodynamic instability in the polytraumatized patient is a predominant feature and most commonly secondary to blood loss accompanying injury. In these patients restoration of intravascular volume attempting to achieve normal systemic pressure faces the risk of increasing blood loss and thereby potentially affecting mortality. ⋯ In patient care, several concepts exist for the reduction of blood loss in conjunction with systemic hypotension: these involve "deliberate hypotension" (synonym "controlled hypotension", used intraoperatively under conditions of normovolemia and stable hemodynamics), "delayed resuscitation" (where the hypotensive period is intentionally prolonged until operative intervention), and "permissive hypotension" (synonym "hypotensive resuscitation", where all kinds of therapy are commenced including fluid therapy, thereby increasing systemic pressure without, however, reaching normotension). In this review the concept of "permissive hypotension" is delineated on the basis of macro- and microcirculatory changes secondary to hypovolemia and low driving pressure, and potential indications as well as limitations for the care of the traumatized patient are discussed.
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Since imbalances in the immune system of the critically ill patient have been demonstrated, the role of the gastrointestinal tract for the pathogenesis of multiple organ failure has been a focus of research in intensive care medicine. Particularly, the integrity of the intestinal barrier function has been studied experimentally and clinically. The enormous number of gram-negative bacteria up to 10(11)/ml intestinal liquid inducing the release of significant amounts of endotoxin, is considered to be a vital threat to the intensive care unit (ICU) patient. ⋯ Maintenance of hemodynamic stability is a mainstay of therapy of the critically ill. In addition, the intestinal integrity can be preserved by the early onset of enteral nutrition. Moreover, recent concepts of enteral nutrition using immunomodulating nutrients like omega-3-fatty acids, glutamine, arginine, and nucleotides are under clinical evaluation.
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Introducing a chest tube is a routine emergency procedure in trauma victims. Emergency coniotomy or establishing an intraosseous access, however, are not often necessary, but in individual cases these techniques can be decisive for patient survival. The aim of this study was to present and evaluate a model for teaching these techniques, since the majority of emergency physicians do not have adequate experience in this area. ⋯ These results show that even emergency physicians with many years of practice have too little knowledge about thoracic drainage, even though it is required in the management of trauma victims. Over 80% of the emergency physicians have no experience with certain other emergency measures recommended as lifesaving in individual cases. Despite the criticism that the participants of the workshop were a selected study group, these numbers seem to reflect reality: Institutions with emergency medicine departments have reported considerable and serious deficiencies in providing emergency care to patients with polytrauma. These gaps could be closed by implementing practice-oriented workshops in collaboration with anatomical institutes. As these institutes use fixated corpses for training purposes, the differences in working with living patients would have to be made clear. In spite of this minor restriction, practical exercises could counteract the deficits in the care of emergency patients and should therefore be integrated into a future educational concept on a long-term basis.