Der Anaesthesist
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Implantable devices (implanted pump/implanted catheter and port) are recommended for continuous epidural application of opiates or local anaesthetics in order to reduce hygienic problems during long term epidural medication. No signs of contamination could be found during bacteriologic culture of residual volumes of 30 patients treated with epidural drug delivery systems and of samples collected during an in vitro investigation (incubation of filled external pump systems at body temperature/storage of syringes with a premixed solution of opiate and local anaesthetic for repeated epidural bolus application). As demonstrated in a case report prophylactic antibiotic coverage prior to implantation may be necessary in patients with a preexisting susceptibility to infection. The concentrations of morphine (radioimmuno-assay) and of bupivacaine (gas-solid chromatography) within the reservoir were stable during clinical therapy as well as during the in vitro experiments.
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Nosocomial pneumonia is a major risk for long term ventilated ICU patients. The infection route may be hematogenic or via inhalation or aspiration of microorganisms. The source of aspiration is the oropharynx. ⋯ During enteral nutrition, 31,4% of the aspirates were sterile, whereas during parenteral nutrition only 24,3% of the gastric aspirates were sterile. Therefore, enteral nutrition should be started as soon as possible, the pH-value should be checked frequently and should not exceed 4 in order to reduce bacterial overgrowth in the stomach. A further consequence is to use as few antibiotics as possible.
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A 40 year old man, who was suspected on clinical evidence (fever, severe muscle pains, dark urine following general anesthesia 8 years ago) of being susceptible to malignant hyperthermia, was scheduled for traumatologic surgery. Dantrolene-Sodium 4 mg/kg orally was given prophylactically the day before surgery; as a premedication the patient received morphine and triflupromazine intramuscularly. ⋯ The remainder of the postoperative course was uneventful. The patient was discharged 9 days later.
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Case Reports
[Malfunction of equipment by the addition of a bacterial filter in the expiratory branch of the respiratory circuit].
The addition of a continuous Flow System to the circuit of a volume cycled respirator results in an additional IMV option and shows excellent performance for this purpose. The insertion of a bacterial filter into this modified circuit resulted in a dangerous increase of airway pressures after 54 "running hours" for that filter. ⋯ Furthermore it was demonstrated that wet bacterial filters cause malfunction of SIMV systems due to interference with the demand valve responsible for proper air supply. The routine use of a bacterial filter placed in the expiratory branch results in higher risks in an already risky artificial ventilation system and use-nonuse relationships seem to be questionable.