Der Anaesthesist
-
An 81-year-old patient had prolonged competitive neuromuscular blockade with train-of-four ratios of 0.1 and 0.5, respectively, after two successive anaesthesia procedures (enflurane-N2O/O2; vecuronium-succinylcholine-sequence) for transurethral prostate resection. Although antagonism with neostigmine was promptly successful after the first, 65-min period of anaesthesia (1.5 mg vecuronium for precurarization, 100 mg succinylcholine for intubation, 3 mg vecuronium), repetitive and chronologically staggered administration of neostigmine after the second, 30-min period of anaesthesia (1 mg vecuronium for precurarization, 100 mg succinylcholine for intubation) had hardly any effect, so that the patient had to be ventilated mechanically for a total of 4.5 h. Laboratory analysis revealed homozygous, atypical, plasma cholinesterase (790 U/l; dibucaine number 23; genotype E1aE1a). ⋯ It must be assumed that a complete phase II block developed after the first succinylcholine exposure owing to the longer duration of anaesthesia; the purely competitive component (train-of-four ratio 0.1) was easily antagonized by neostigmine. At the time of the attempted antagonism after the second, shorter period of anaesthesia, however, block transformation was still incomplete (train-of-four ratio 0.5). The administration of neostigmine therefore rather intensified the depolarization segment of the mixed block, so that repeated attempts at antagonism then inhibited any further block transformation.
-
Intrinsic positive end-expiratory pressure (PEEPi) occurring during mechanical ventilation depends on expiratory time constants, expiratory volume and expiration time as well as on external flow resistance (tubes, valves, etc.). It is not routinely determined in mechanically ventilated patients, but it is necessary to optimize respirator settings. The aim of the present study was the validation of an automated PEEPi determination method implemented in the respirator EVITA (Drägerwerke, Lübeck) in mechanically ventilated patients with acute lung failure. ⋯ Unfortunately, PEEPi measurement of the EVITA can only be performed during controlled and not during assisting (PSV, BIPAP etc.) ventilation. Optimal respirator settings require a knowledge of PEEPi (i.e., adaption of external PEEP for lowering the work of breathing in COPD patients or prolongation of the expiratory phase to avoid unwanted side effects of an occult PEEPi on the circulation). Since mo
-
At Leipzig University, preoperative pulmonary function testing has been performed for about 3 years in order to detect and classify patients at high pulmonary risk. During the postoperative period, the risk of developing pulmonary complications is particularly high due to factors influencing respiratory mechanics such as the supine position, pain, residual effects of narcotic drugs, etc. It has often been emphasised that an underlying ventilatory disturbance such as obstructive lung disease or smoking may enhance the postoperative pulmonary risk, although the extent of the influence of preoperative pulmonary diseases on the postoperative complication rate is still controversial. ⋯ For minimising perioperative pulmonary complications, respiratory care (prophylaxis and therapy) adequate for the functional risk of the patient is necessary. We assume that intensive pre- and postoperative respiratory care and therapy in patients with underlying reductions in ventilatory function can help to avoid or reduce respiratory complications. The modification of Miller's scheme proposed after evaluating the postoperative course of our patients provides a differentiated prognostic model that allows the establishment of an appropriate and economical therapeutic regimen of perioperative pulmonary care.
-
The hospital nursing staff represents a distinct group of cardiopulmonary resuscitation (CPR) providers. Differences in the success rates of resuscitation attempts inside or outside the hospital seem to be attributable to the skill of the various rescuers. Whereas the definite success rate for prehospital resuscitation is 7%, the corresponding rate for in-hospital settings is 15%. ⋯ Indeed an increasing rate of successful resuscitations inside the hospital (up to 27%) has been reported in the literature. In consequence of our findings, refresher courses in specific CPR techniques must be demanded, which should be made obligatory for nursing staff every 2 years. Qualified nursing personnel routinely trained in CPR and supported by effective hospital logistics is essential if the life-saving benefits of modern CPR are to be provided to our patients.
-
Randomized Controlled Trial Comparative Study Clinical Trial
[Total i.v. anesthesia with S-(+)-ketamine in orthopedic geriatric surgery. Endocrine stress reaction, hemodynamics and recovery].
Clinically-used ketamine is a racemic mixture of two isomers, S-(+)- and R-(-)-ketamine. Previous investigations showed the anaesthetic potency of S(+)-ketamine to be three times higher than that of R-(-)-ketamine. It was the aim of this study to compare the effects of S-(+)-ketamine and racemic ketamine on endocrine and cardiovascular parameters, recovery, and side effects in geriatric patients during total intravenous anaesthesia (TIVA) for orthopaedic surgery. ⋯ Increases in cardiovascular parameters and insufficient reduction of the stress response with respect to ADH, ACTH, and cortisol seem to require a more potent hypnotic element during TIVA with ketamine. With regard to endocrine and cardiovascular parameters, the pharmacodynamic effects of racemic and S-(+)-ketamine were comparable. Because of the significant improvement in recovery and the reduced quantitative drug load, S-(+)-ketamine offers a clinical advantage compared with currently used racemic ketamine.