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Der Anaesthesist [journal]
- [Catheter complications in persistent left superior vena cava.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 29.
- [Pharmacokinetics and pharmacodynamics of antibiotic therapy.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 24.
Antibiotic agents are crucial pillars in intensive care medicine and must be used rationally and sensibly. In the case of critically ill patients optimal dosing with respect to pharmacokinetic and pharmacodynamic principles (PK/PD) can be vital. Preclinical results demonstrated important differences between antibiotic classes and gave rise to differing clinical dosing strategies, e.g. high dose once daily regimens for aminoglycosides or extended/continuous infusion of betalactams. Critically ill patients with altered pharmacokinetic parameters and infections by pathogens with low susceptibility are most likely to benefit from PK/PD-guided therapy.
- [Correct performance of transfusion.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 22.
The administration of blood products is strictly regulated. Warming of blood components at body temperature is required only in rare cases. Addition of drugs to blood products is not allowed. During transfusion the monitoring of the patient is continued. In the case of an adverse event, exclusion of acute hemolysis is very important. As emergency transfusions have a higher risk than standard transfusions, their indications have to be restricted. When transfusion is completed the blood bag has to be preserved for 24 h. The effects of the blood transfusion have to be controlled. The administration of blood products must be documented to allow a possible cross-check from the recipient to the donor as well as from the donor to the recipient. The disposal of administered and of non-administered blood components is subject to the guidelines for hospital waste.
- [General anesthesia for ambulatory surgery : Clinical pharmacological considerations on the practical approach.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 20.
Due to modern surgical and anesthesia techniques, many patients undergoing small or even medium surgical procedures will recover within minutes and can then be discharged after a few hours of monitoring. Aside from an optimized surgical technique, a precise and differentiated anesthesia concept is needed to guarantee rapid recovery and home readiness. Nowadays, remifentanil-propofol represents the standard regime in ambulatory anesthesia. The use of alfentanil, desfluran or sevofluran is also possible whereas other intravenous or inhaled anesthetics or other opioids are rarely used. If endotracheal intubation is necessary, a reduced intubating dose of neuromuscular blockers (NMB), such as mivacurium, atracurium and rocuronium, i.e. 1-1.5-times the 95 % effective dose (ED95) is a good possibility to accelerate neuromuscular recovery while still having acceptable intubation conditions. Due to its limitations and contraindications, succinylcholine is not the first choice but may be used in non-fasting patients in need of urgent (ambulatory) surgery, e.g. in bleeding women undergoing dilation and curettage. Even with these reduced dosages monitoring of neuromuscular recovery is crucial and should be applied to all patients when NMBs are used. Furthermore, patients should receive a risk-adapted postoperative nausea and vomiting (PONV) prophylaxis, e.g. with 4 mg dexamethasone and 4 mg ondansetron. Postdischarge nausea and vomiting (PDNV) should be anticipated by a new risk score and prophylaxis or treatment should be initiated. For postoperative pain relief, local or regional anesthesia techniques, such as infiltration, field or nerve blocks should be applied where possible. In addition, non-opioid analgesics are the basic treatment while longer-lasting opioids are only necessary for some patients.
- [Survey on the need for information during the preanesthesia visit.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 8.
The preanesthesia informed consent document is regarded mainly as a legal prerequisite but patient autonomy in the authorization of a proposed intervention requires that the relevant information is provided in a suitable and useful way.The information needs of patients was determined in relation to demographic parameters. This study carried out to evaluate if the expected extent of information regarding anesthesia during the preanesthesia visit was dependent on group-specific variables.A total of 699 adult patients with forthcoming elective non-cardiac surgery were anonymously interviewed concerning their expectations and informational needs during the preanesthesiavisit. The questionnaire contained 15 demographic variables, one being the question on health-related quality of life (HRQoL). The ASA classification was the only patient data assessed by the anesthesiologist after the consultation. In the second part of the questionnaire statements regarding the kind and extent of information (n = 10) as well as structural aspects of the preanesthesia visit (n = 5) could be rated using a four-step Likert scale. Point values from questions 1-10 were added to a sum score of need for information for each patient with 0 to ± 3 allotted for each question according to the direction of the question wording (i.e. more or less information desired) and the individual patient scores on the Likert scale. Variables associated with this score of need for information were assessed by regression analysis.Of the patients, 80.6 % were classified as American Society of Anesthesiologists (ASA) physical status I and II. The HRQoL was rated fair or good by a total of 80 %. On average patients were satisfied with the extent and the kind of information offered during the preanesthesia visit with a mean of the sum score of 0 (min. - 10 and max. + 10, SD ± 3.2). This applied to the written material to prepare for informed consent; however, the consultation was much more appreciated as a source of information. Of the patients, 278 wanted more information and 268 patients wanted less. Linear regression analysis determined education [p = 0.00018, 95 % CI: 0.405 (0.194-0.615)], ASA physical status [(p = 0.047, 95 % CI: - 0.558 (- 1.107 to - 0.009)] and HRQoL [(p = 0.025, 95 % CI: - 0.412 (- 0.771 to - 0.053)] as being independently related to information needs, including perioperative processes as well as rare risks and complications. Interest in being educated about patient autonomy in end of life situations in the hospital was significantly correlated to the score (p < 0.001, r = 0.143). The results of this study demonstrate for the first time in a German surgical cohort a wide acceptance of preoperative healthcare planning (77.4 %).Demographic criteria can help to tailor pre-anesthetic information to individual patient needs. The explanatory power of these variables was, however, low. The relationship between self-assessed HRQoL and the demand for information underlines the necessity to adapt the amount and kind of information provided during the consultation to individual patients preferences.
- To what extent can local anesthetics be reduced for infraclavicular block with ultrasound guidance? [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 8.
To assess the adequacy of different amounts of local anesthetics (LA) in infraclavicular blockade (ICB) under ultrasonographic (US) guidance and neurostimulation and compare them to the conventional doses under neurostimulation (NS).In this study 100 patients scheduled for upper limb surgery and suitable for ICB were randomly allocated to 1 of 5 groups: group NS (NS alone group 0.5 ml/kg LA), group FD (full-dose US group 0.5 ml/kg LA), group 30 (30 % reduced dose LA 0.35 ml/kg), group 50 (0.25 ml/kg LA) and group 70 (0.15 ml/kg LA). The ICB was performed under US in conjunction with NS in all groups except group NS in which neurostimulation was used alone. When necessary local anesthetic supplementation to the operation site was administered during surgery and propofol infusion for sedation ensued. Evaluation of sensory and motor block was performed for each terminal nerve (i.e. radial, ulnar, median and musculocutaneous nerves). Block quality (assessing the need for rescue LA and propofol sedation) and duration of the block were documented.None of the patients in the FD and 30 groups required any supplementation or sedation, whereas LA supplementation rates were 5 % in group 50 and 10 % in groups 70 and NS. The propofol sedation rates were 20 % in group NS, 25 % in group 50 and 40 % in group 70. Sensory block was significantly better in groups FD, 30 and NS at 30 min. A complete block was achieved more rapidly in all nerve territories in the full-dose group (p = 0.0001). Block duration was longest in group FD and was significantly longer in group 30 than in the other two groups (p = 0.0001).The results show that US guidance is more effective in maintenance of successful ICB than neurostimulation guidance alone and a reduction of LA doses even to 70 % of conventionally used doses seems possible with US guidance. This article is published in English.
- [Correct preparation of a transfusion : Part 1.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Aug 3.
The administration of blood products is strictly regulated. Several weeks before the operation the preparation for transfusion begins with optimizing the patient's hematological and hemostaseological situation. In elective surgery blood group testing and antibody screening are performed soon after admission of the patient. The identification of the blood sample is important. Informed consent of the recipient has to be obtained. On the day before the operation a further blood sample is necessary for cross-matching if red blood cells are to be transfused. Usually blood products are issued for immediate administration. Before transfusion begins the blood product has to be checked, the identity of the patient must be controlled and in the case of red blood cell transfusions the AB0 bedside test has to be performed.
- [Veno-arterial extracorporeal membrane oxygenation : Indications, limitations and practical implementation.] [JOURNAL ARTICLE]
- Anaesthesist 2014 Jul 31.
Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.