Der Anaesthesist
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Sevoflurane may be an interesting substance for paediatric anaesthesia due to its combination of a very low blood-gas partition coefficient and non-pungency. This review discusses the status of sevoflurane in paediatric anaesthesia on the basis of studies published so far. The blood-gas partition coefficient of sevoflurane in children is 0.66, and hence markedly lower than those of isoflurane (1.25) and halothane (2.26) [15]. ⋯ The incidence of postoperative nausea and vomiting after sevoflurane anaesthesia is comparable to that after halothane (Table 2). Sevoflurane may be a user-friendly alternative to halothane and is more preferred by children than halothane [32]. The status of sevoflurane in paediatric anaesthesia will depend on several factors: its own benefit/risk-ratio, a possible re-evaluation of the known risks of halothane and the financial limitations of the hospitals.
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Polymorphonuclear leukocytes (PM-NL) constitute the first line of defence in the protection of the host from invading microorganisms. PMNL also contribute to the removal of cellular debris from necrotic tissues during reparative processes. For these purposes PMNL are armed with highly efficient bactericidal mechanisms which, under certain pathophysiological conditions, can be turned against the host himself. ⋯ The manifestation of ARDS in leukopenic patients, however, indicates the development of this clinical syndrome independently of the presence of PMNL. The ability to differentiate between PMNL-dependent and PMNL-independent pathways in the pathogenesis of this syndrome is not only of theoretical interest but also of therapeutic significance. Since the patient's systemic inflammatory response may vary according to the stage and type of the underlying disease, an exact qualitative and quantitative analysis of PMNL functions may provide the rationale for new anti-inflammatory drug regimens aimed at modifying the host's response without increasing the risk of infection.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Incidence and quality of dreaming during anesthesia with propofol in comparison with enflurane].
Since the introduction of propofol into clinical practice, dreaming during general anaesthesia has been frequently reported with this drug. We investigated the incidence and character of these dreams with regard to distinction from intraoperative awareness and in comparison with habitual dreams or dreams during general anaesthesia with enflurane. ⋯ We conclude that sensory experiences during propofol anaesthesia are not stimulus-related perceptions or awareness, but dreams similar to normal ones. In view of the absence of clear signs of stimulus-related response, we presume that dreaming is a specific side effect of propofol. Because of the absence of difficulties, dreaming during propofol anaesthesia appears not to be a disadvantage with regard to the quality of anaesthesia.
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The on-scene performance during all missions of the emergency physician-operated rescue helicopter and mobile intensive care unit based at a large-city hospital over a period of 1 year was retrospectively analysed; 2,254 hospital discharge reports were available (92% of the patients treated by the emergency physicians [n = 2,493]). The following parameters were investigated: reliability of the primary diagnosis established by the emergency physician (by comparison with the discharge diagnoses); initial on-scene therapeutic measures; means of transportation (with or without accompanying emergency physician); and level of care of the target hospital. ⋯ In the context of quality management measures, a careful evaluation of on-scene diagnoses, therapeutic measures, and decisions made by the emergency physician is a suitable procedure for identifying systematic errors. A high percentage of correct diagnoses and therapy at the emergency site can only be ensured by clinically experienced physicians who constantly deal with patients with acutely life-threatening conditions.
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Case Reports
[Treatment reduction in intensive care. "Allowing the patient to die" by conscious withdrawal of medical procedures].
The conversion of an "attempt to treat" to "prolongation of dying" represents an important problem in modern intensive care. If the actual or presumed will of the patient is unknown, the physician has to decide about the extent of treatment in a paternalistic manner. In these difficult decisions the physician has to consider prognosis, and certainty of prognosis and has to carefully balance between the right to live and the right to die. ⋯ If the situation is hopeless and further medical interventions are futile, then allowing the patient to die by therapy reductions is not only a possibility but a mandatory act of humanity. In that case it does not matter whether new treatment modalities are abandoned or whether already instituted medical measures are withdrawn. In clinical practice, however, the "fine tuning" of therapy reduction has to be tailored to the individual case and largely depends on prognostic certainty.