Articles: critical-care.
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Klinische Wochenschrift · Jan 1991
Review[Use of hypertonic saline solutions in intensive care and emergency medicine--developments and perspectives].
The primary factor rendering patients at risk of developing multiple system organ failure after shock and trauma is the persistence of impaired microcirculation along with its sequelae for cellular and organ function. Bolus infusion (2-5 min) of 4 ml/kg hypertonic/hyperoncotic saline solution through a peripheral vein is a new concept for primary resuscitation from severe hypovolemia associated with trauma and hemorrhage and is termed "small-volume resuscitation". The experimental data obtained by various research groups have demonstrated the efficacy of 7.2%-7.5% saline solution in restoring central hemodynamics and organ blood flow. ⋯ Of particular importance are the data obtained in experiments on traumatic-hemorrhagic hypovolemia in beagles, which proved that the infusion of 10% dextran 60 in 7.2% saline (hypertonic-hyperoncotic solution) restores nutritional blood flow within less than 5 min, thereby enhancing the circulatory effect of hypertonic saline alone. In the pre-clinical setting, small-volume resuscitation by means of hypertonic saline/dextran solution is aimed at the rapid normalization of the compromised microcirculation and, thus, at the prevention of late complications such as sepsis and multiple system organ failure. The novelty of hypertonic saline/dextran resuscitation lies in its operational mechanism at the microcirculatory level, which also renders this concept attractive for volume support in endotoxemia and septic shock.(ABSTRACT TRUNCATED AT 250 WORDS)
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Klinische Wochenschrift · Jan 1991
Review[Disorders of blood coagulation in the intensive care unit: what is important for diagnosis and therapy?].
In the haemostatic system there is normally a stable balance between its components (vessel wall, platelets, coagulation, fibrinolysis), which are in continuously close interaction. Disturbances of this balance may lead to bleeding, thrombosis, or thrombohaemorrhagic consumptive disorders. The task of haemostaseologic diagnostics is to discover eventual preexisting but as yet undiagnosed disturbances in any patient entering an intensive care unit and, in cases of acute bleeding, to provide useful information that facilitates therapeutic decisions. ⋯ Promising attempts to overcome DIC via substitution of antithrombin III and fresh frozen plasma are discussed. Optimal management of complications and monitoring of therapy requires the close teamwork of attending surgeons or physicians and haemostaseologists. The purpose of any therapy is to preserve or regain the balance of haemostasis.
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Klinische Wochenschrift · Jan 1991
Review[How painful is long-term ventilation? Considerations on the importance of analgesia within the scope of analgosedation].
The goal of analgesia and sedation in intensive care units is most often achieved using numerous drug combinations, mostly justified by physicians' and nurses' habits instead of rational pharmacological criteria for the choice of drugs and dosages. The present paper aims at defining the analgesic situation of ventilated intensive care patients and concludes from analogy with other, better understood states of pain that the importance of analgesic drugs is frequently overrated. To achieve effective analgesia and sedation in individual patients, the dosage must be titrated to individual needs. The author suggests that standardized baseline analgesia should be used, which enables sedation to be titrated, whereas the opposite is not practicable in clinical routine.
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The patterns of recovery of patients who received seven different analgesic and sedative treatments were investigated with regard to the time at which the subjects awoke. For observations of the neurologic status, we developed a special score. ⋯ Piritramid/promethazine, pethidine/flunitrazepam, pethidine/promethazine and tramadol/methohexital required more time for awakening. On the basis of these results, we prefer to use the combination of fentanyl/midazolam, alfentanil/midazolam and ketamine/flunitrazepam to judge all patients' neurologic scores.
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Recent therapeutic advances in inotropic drugs and vasipressors uses allow a reappraisal of their indications during the perioperative period. Non-catecholamines vasopressors, ephedrine and phenylephrine, are particularly suitable for treatment of abrupt peroperative arterial hypotensions as observed during induction of general and medullar anesthesias. Cardiac arrest, peroperative anaphylactoid and toxic accidents are treated with epinephrine. ⋯ Inodilators (enoximone, amrinone and milrinone) ans nex dopaminergic compound (dopexamine) are powerful vasodilators agents to be introduced with care when association of amines and current vasodilators have failed. Finally, arterial pressure has to be maintained with norepinephrine after dopamine failure. Epinephrine remains last chance.