Der Anaesthesist
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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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A 41-year-old woman with severe juvenile diabetes mellitus suffered from profound hypothermia after loss of thermoregulation in diabetic ketoacidosis. She was found unconscious, without measurable blood pressure; the electrocardiogram (ECG) showed bradycardia of 30 min and the rectal temperature was 23.7 degrees C. The patient received mechanical ventilation, fluid therapy, warmed gastric lavage, and, unfortunately, inotropic medication. ⋯ Sinus rhythm resumed without antiarrhythmic medications at a temperature of 29.5 degrees C, and within 8 h the patient was rewarmed to 35.5 degrees C. After treatment of the adult respiratory distress syndrome caused by pneumonia, she was discharged from the intensive care unit to complete treatment with no evidence of any permanent organ damage. We conclude that hemofiltration may be the method of choice for rewarming deeply hypothermic patients when their circulation is preserved.(ABSTRACT TRUNCATED AT 250 WORDS)
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After laparoscopic cholecystectomy, carbon dioxide (CO2) must be exhaled after resorption from the abdominal cavity. There is controversy about the amount and relevance of postoperative CO2 resorption. Without continuous postoperative monitoring, after laparoscopic cholecystectomy a certain risk may consist in unnoticed hypercapnia due to CO2 resorption. ⋯ There is no significant resorption of CO2 from the abdominal cavity later than 30 min after releasing the KP. Up to this time, any CO2 remaining in the abdominal cavity after careful emptying by the surgeon has been resorbed and exhaled. An increased PeCO2 as late as 30 to 90 min postoperatively should rather be considered a consequence of residual anaesthetics and narcotics than of CO2 resorption.
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Case Reports
[Difficult intubation due to facial malformations in a child. The laryngeal mask as an aid].
Variations in anatomy of the bony and soft-tissue structures of the neck and facial cranium due to trauma, disease, or dysmorphic syndromes may lead to severe intubation problems. These patients are admitted for mandibulofacial and otolaryngologic surgery. It is important to inspect the patient's outer and inner pharyngeal structures carefully during preoperative assessment, as suggested by Mallampati. ⋯ The patient's jaw was hypoplastic with aplasia of the temporo-mandibular joint, which led to asymmetry of the lower face and an extremely short mandible. Additionally, we observed a large tongue in relation to the small jaw. Macrostomia is part of the syndrome, and may lead to underestimation of intubation problems.(ABSTRACT TRUNCATED AT 250 WORDS)