Der Anaesthesist
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Intensive care unit-acquired weakness (ICUAW) is a severe complication in critically ill patients which has been increasingly recognized over the last two decades. By definition ICUAW is caused by distinct neuromuscular disorders, namely critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Both CIP and CIM can affect limb and respiratory muscles and thus complicate weaning from a ventilator, increase the length of stay in the intensive care unit and delay mobilization and physical rehabilitation. ⋯ For the diagnosis, careful physical and neurological examinations, electrophysiological testing and in rare cases nerve and muscle biopsies are recommended. Nevertheless, it appears to be difficult to clearly distinguish between CIM and CIP in a clinical setting. At present no specific therapy for these neuromuscular disorders has been established but recent data suggest that in addition to avoidance of risk factors early active mobilization of critically ill patients may be beneficial.
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Scoring systems are used in all diagnostic areas of medicine. Several parameters are evaluated and rated with points according to their value in order to simplify a complex clinical situation with a score. The application ranges from the classification of disease severity through determining the number of staff for the intensive care unit (ICU) to the evaluation of new therapies under study conditions. ⋯ The scoring systems that are employed in intensive care and are discussed in this article can be categorized into prognostic scores, expenses scores and disease-specific scores. Since the introduction of compulsory recording of two scoring systems for accounting in the German diagnosis-related groups (DRG) system, these tools have gained more importance for all intensive care physicians. Problems remain in the valid calculation of scores and interpretation of the results.
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The rate of Caesarean sections in Germany continues to rise. The change in anesthetic technique of choice from general to spinal anesthesia began later than in other countries and at the last survey in 2002 was not widely established. The literature on the anesthetic management of Caesarean sections contains many controversies, for example fluid preload before performing spinal anesthesia and the vasopressor of choice. Other issues have received relatively little attention, such as the level of experience of anesthesiologists working autonomously on the labour ward or the timing of antibiotic prophylaxis. The aim of the current survey was to provide an updated overview of anesthetic management of Caesarean sections in Germany. ⋯ Currently the predominant anesthetic technique of choice in Germany is spinal anaesthesia and at a much higher rate than in 2002. In addition 12% of departments use traumatic Quincke needles which are associated with a higher incidence of postpuncture headache. Nitrous oxide is no longer frequently used in Germany. Finally, the administration of an antibiotic before cord clamping has been shown to lead to lower rates of endometritis and postoperative wound infection without detrimental effects on the newborn. This is practiced in only a small minority of departments across Germany.
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The probability of treating patients with valvular heart disease during non-cardiac surgery increases with the age of the patient. The prevalence of valvular heart disease is approximately 2.5% and increases further in the patient group aged over 75 years old. Patients with valvular heart disease undergoing non-cardiac surgery have an increased perioperative cardiovascular risk depending on the severity of the disease. ⋯ Depending on the underlying disease and the type of surgery planned a corresponding choice of anesthesia procedure and medication must be made. In the present review article the pathophysiology of the relevant valvular heart diseases and the implications for perioperative anesthesia management will be presented. An individually tailored extended perioperative monitoring allows hemodynamic alterations to be rapidly recognized and adequately treated.
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Surgical interventions in the sitting position are intended to optimize surgical conditions by reducing bleeding in the operation field and improving the surgical approach. There are, however, some potentially life-threatening risks associated with surgery in the sitting position. ⋯ In addition to standard monitoring procedures, transthoracic Doppler ultrasound and transesophageal echocardiography are valuable methods used to detect the presence of air in the vasculature. If an air embolism becomes apparent, further targeted measures are needed to prevent or aggressively treat the progression of potentially life-threatening consequences.