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Der Anaesthesist [journal]
- [Ventilator-induced diaphragm dysfunction : Clinically relevant problem.] [JOURNAL ARTICLE]
- Anaesthesist 2013 Dec 5.
Mechanical ventilation is a life-saving intervention for patients with respiratory failure or during deep sedation. During continuous mandatory ventilation the diaphragm remains inactive, which activates pathophysiological cascades leading to a loss of contractile force and muscle mass (collectively referred to as ventilator-induced diaphragm dysfunction, VIDD). In contrast to peripheral skeletal muscles this process is rapid and develops after as little as 12 h and has a profound influence on weaning patients from mechanical ventilation as well as increased incidences of morbidity and mortality. In recent years, animal experiments have revealed pathophysiological mechanisms which have been confirmed in humans. One major mechanism is the mitochondrial generation of reactive oxygen species that have been shown to damage contractile proteins and facilitate protease activation. Besides atrophy due to inactivity, drug interactions can induce further muscle atrophy. Data from animal research concerning the influence of corticosteroids emphasize a dose-dependent influence on diaphragm atrophy and function although the clinical interpretation in intensive care patients (ICU) patients might be difficult. Levosimendan has also been proven to increase diaphragm contractile forces in humans which may prove to be helpful for patients experiencing difficult weaning. Additionally, antioxidant drugs that scavenge reactive oxygen species have been demonstrated to protect the diaphragm from VIDD in several animal studies. The translation of these drugs into the IUC setting might protect patients from VIDD and facilitate the weaning process.
- [Invasive candidiasis in non-neutropenic adults : Guideline-based management in the intensive care unit.] [JOURNAL ARTICLE]
- Anaesthesist 2013 Dec 5.
Invasive Candida infections represent a diagnostic and therapeutic challenge for clinicians particularly in the intensive care unit (ICU). Despite substantial advances in antifungal agents and treatment strategies, invasive candidiasis remains associated with a high mortality. Recent guideline recommendations on the management of invasive candidiasis by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) from 2012, the German Speaking Mycological Society and the Paul Ehrlich Society for Chemotherapy (DMykG/PEG) from 2011 and the Infectious Diseases Society of America (IDSA) from 2009 provide valuable guidance for diagnostic procedures and treatment of these infections but need to be interpreted in the light of the individual situation of the patient and the local epidemiology of fungal pathogens. The following recommendations for management of candidemia are common to all three guidelines. Any positive blood culture for Candida indicates disseminated infection or deep organ infection and requires antifungal therapy. Treatment should be initiated as soon as possible. Removal or changing of central venous catheters or other foreign material in the bloodstream is recommended whenever possible. Ophthalmological examination for exclusion of endophthalmitis and follow-up blood cultures during therapy are also recommended. Duration of therapy should be 14 days after clearance of blood cultures and resolution of symptoms. Consideration of surgical options and a prolonged antifungal treatment (weeks to months) are required when there is organ involvement. During the last decade several new antifungal agents were introduced into clinical practice. These innovative drugs showed convincing efficacy and favorable safety in randomized clinical trials. Consequently, they were integrated in recent therapeutic guidelines, often replacing former standard drugs as first-line options. Echinocandins have emerged as the generally preferred primary treatment in candidemia. The expert panel of ESCMID views fluconazole only as a marginally recommended therapy for this indication. The use of amphotericin B deoxycholate should be generally avoided because of toxicity.
- [Comments on: long-term cognitive impairment after intensive care therapy.] [JOURNAL ARTICLE]
- Anaesthesist 2013 Nov 30.
- [Perioperative approach to restless legs syndrome.] [JOURNAL ARTICLE]
- Anaesthesist 2013 Nov 30.
Restless legs syndrome (RLS) is one of the most common neurological disorders. The key feature is the urge to move, especially in the legs. New onset RLS can develop perioperatively or an existing RLS can be exacerbated. Severe insomnia, forced immobilization and acute iron deficiency are common trigger factors. Medicinal treatment can also be an important triggering or exacerbating factor. Drugs with dopamine antagonistic, serotonergic and opioid antagonistic effects should be avoided. The long-term medicinal treatment should be terminated as quickly as possible and if necessary bridged non-orally. For diseases which can be associated with secondary RLS a provocation or an exacerbation of RLS should be taken into consideration. This is particularly true for Parkinson's disease, diabetes mellitus, terminal renal insufficiency, spinal cord lesions and pregnancy. So far, there is not sufficient evidence that any form of anesthesia has a negative influence on RLS.
- Impaired long-term quality of life in survivors of severe sepsis : Chinese multicenter study over 6 years. [JOURNAL ARTICLE]
- Anaesthesist 2013 Nov 30.
The present study was undertaken to evaluate the long-term health-related quality of life (HRQOL) as well as the employment status in survivors of severe sepsis up to 6 years afterwards.From January 2003 to December 2008 a total of 112 severe sepsis and 112 age, gender and Charlson comorbidity index-matched non-septic critically ill patients from 4 university hospital intensive care units (ICU) were enrolled in the study and 126 age and gender-matched community residents were interviewed as the community control group.A total of 66 (58.9 %) severe sepsis and 80 (71.4 %) non-sepsis critically ill patients survived during the long-term follow-up time. Between August and December 2010 a total of 75 patients including 42 survivors of severe sepsis and 33 critically ill controls completed the face-to-face interview. There were no differences in the long-term HRQOL in terms of Short-Form 36 criteria between severe sepsis and non-sepsis critically ill survivors. However, when compared with the community controls, HRQOL in survivors of severe sepsis showed a significantly and clinically meaningful decrease, with a lower physical functioning (p = 0.016), vitality (p = 0.037), role-emotional (p = 0.043), mental health (p = 0.038) and mental component scores (p = 0.042). In addition, the criteria returning to work at 1 year and at the time of interview in severe sepsis survivors were similar with those in critically ill survivors (60.5 % vs. 70.0 %, p = 0.41 and, 71.1 % vs. 76.7 %, p = 0.602).The HRQOL in survivors of severe sepsis was impaired even up to 6 years after hospital discharge.
- [Ultrasound in interventional pain therapy]. [English Abstract, Journal Article]
- Anaesthesist 2013 Nov; 62(11):931-46.
Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.
- RETRACTED ARTICLE: Different anesthesia methods for laparoscopic cholecystectomy. [Journal Article]
- Anaesthesist 2013 Nov; 62(11):913.
- [Pharmacogenetics : Clinical relevance in anesthsiology]. [English Abstract, Journal Article]
- Anaesthesist 2013 Nov; 62(11):874-86.
Pharmacogenetics deals with hereditary factors which influence the pharmacodynamics and pharmacokinetics of drugs leading to individual diverse reactions. Also in anesthesiology differences in the pharmacogenetics of patients can lead to relevant alterations in the pharmacodynamics of drugs.This article provides a summary of polymorphisms relevant to commonly used anesthetic agents and the clinical relevance in patients treated with these compounds. It describes the possibilities, the problems and limits of pharmacogenetic diagnostics and therapy and explains how this follows the target of individualized medicine.This article describes in detail the alterations in pharmacodynamics and pharmakokinetics relevant for anesthesia and their clinical significance. Based on the results of current studies, an overview of the most important drugs in anesthesiology with significant polymorphisms is given. These include opioids, muscle relaxants, volatile anesthetic agents, non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antiemetics and cardiovascular drugs as well as platelet aggregation inhibitors, anticoagulants and the so-called new oral anticoagulants.Genetic alterations can lead to substantial modifications in the effectiveness of drugs. Genetic alterations of opioid receptors and the enzyme cytochrome P450 (CYP) 2D6 can result in a failure of analgesia after administration of opioids. Alterations in plasma cholinesterase activity are associated with a prolonged effectiveness of muscle relaxants. Polymorphisms in ryanodine receptors can contribute to the development of the feared MH in patients after administration of volatile anesthetics or succinylcholine.The study results presented here emphasize that these days knowledge on pharmacogenetics should not be missing in modern induction of anesthesia. In the future a blood sample could enable physicians to identify pharmacologically relevant markers. And these could guide the decision on the prescription of drugs and their appropriate dose, in order to achieve the lowest risk of side effects and the highest effectiveness of the active substance.
- [Decision of the European Medicines Agency on hydroxyethyl starch : Important step towards therapeutic and legal security]. [Journal Article]
- Anaesthesist 2013 Nov; 62(11):869-71.
- [Management of critically ill patients in the resuscitation room : Different than for trauma?] [JOURNAL ARTICLE]
- Anaesthesist 2013 Nov 24.
The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.