Kombination von β-Blockern mit Dobutamin

Ohne Zusammenfassung     

Nutzen der perioperativen β-Blockade

BACKGROUND: The perioperative administration of beta blockers is a controversial issue. Numerous trials failed to show any significant benefit or disadvantage because of low event rates and insufficient statistical power.METHODS: In July 2005 McGory et al. and Devereaux et al. separately published 2 meta-analyses, raising the question of the perioperative administration of beta blockers for patients undergoing non-cardiac surgery. In February 2006, Schouten et al. published an additional meta-analysis concerning the same question. This evidence is supplemented by the publication of Lindenauer et al. in 2005. These trials will be critically appraised in this review.RESULTS: McGory et al. concluded from their data that the perioperative administration of beta blockers significantly reduced cardiovascular mortality. However, this conclusion is clearly not valid because of methodological deficits of the meta-analysis. In addition, the publications by Devereaux et al. and Schouten et al. did not support the results of the analysis by McGory et al. CONCLUSIONS: There is still no clear evidence to prove a significant benefit for the unselected perioperative use of beta blockers in patients undergoing non-cardiac surgery. While high-risk patients and those undergoing major surgical procedures seem to profit, low-risk patients may be more harmed than helped by this intervention. The fact that 3 meta-analyses raising the same question produced substantially different results, underlines the importance of critically appraising each meta-analysis.     

Kontinuierliche lokale Wundinfusion mit Lokalan?sthetika

Wound infusion with local anesthetics is a nearly 100 years old proven and secure analgesic method. Recently special wound infusion catheters have become available which can be placed intraoperatively into the wound under direct supervision of the surgeon to infuse local anesthetics and optimize postoperative analgesia. For thoracotomy this method was modified to improve its efficacy and the catheters are used to establish a continuous paravertebral intercostal nerve block (PVB). Many studies have confirmed the analgesic power of PVB which results in a pain reduction comparable to thoracic epidural analgesia (TEA) but without TEA-specific side-effects, in particular hypotension. The efficacy of continuous local wound infusion (CLWI) is less obvious for laparotomy. If fundamental preconditions for this loco-regional method are considered (indications, choice of catheter, local anesthetic dose) the laparotomy wound could also be suitable for the use of CLWI. According to the literature currently available CLWI is not associated with an increased risk of wound infections.     

Tempor?re Versorgung einer unstillbaren intrathorakalen Blutung mit Bauchtüchern in Kombination mit einer Rettungsprozedur

Case report of a 27-year-old patient who presented with a stab wound in the posterior aspect of the right chest. The patient was physiologically unstable and not responding to fluid resuscitation. A right intercostal drainage was inserted which immediately drained 1100?ml of blood. Thoracotomy was performed where a large clot was removed from the pleural cavity and followed by massive bleeding from the hilum of the lung as well as an intercostal artery posteriorly. Control of the hilar hemorrhaging necessitated right middle lobe resection. Attempts to control the bleeding from the intercostal artery were futile becoming technically more difficult due to a comminuted fracture of the ribs at the site of entry of the knife. During these attempts the patient became moribund. As a last resort the pleural cavity was packed with abdominal towels and the patient was transferred to the intensive care unit (ICU). The patient was returned to surgery after 48?h at which time the packing was removed with no further bleeding. On day 11 postoperatively drainage of the pleural collection was carried out and decortication of the right lower lobe. The patient was discharged 23 days after admission in a good general condition. This case report demonstrates that in exceptional circumstances packing of the pleural cavity to control bleeding can be considered as a method of damage control in penetrating chest trauma.     

Milde Ganzkörperhyperthermie in Kombination mit stationärer multimodal orientierter Schmerztherapie

Purpose

A randomized controlled clinical trial was implemented to evaluate the effectiveness of combined mild hyperthermia therapy (body core temperature 38.4?°C) and multimodal inpatient rehabilitation for patients suffering from chronic low back pain when compared to multimodal pain therapy alone.

Patients and methods

A total of 88 patients were randomly assigned to the combined or single therapeutic schemes according to a block randomization scheme. According to the trial inclusion criteria all patients suffered from chronic low back pain and showed morphological degeneration. All patients underwent a 12-day inpatient multimodal pain therapy, which was complemented with a 6-session schedule of mild hyperthermia therapy for the intervention group (1 h at 38.6?°C). On admission and 3 months after treatment the study patients were asked to complete an interview assessment with the Oswestry low back pain disability questionnaire (Oswestry disability index). The change in the Oswestry disability index total score (%) 3 months after versus before therapy was defined as the primary clinical endpoint of the investigation. The patients in the control group and in the intervention group had a median age of 50 years. In the intervention group 70?% of the patients were female and 55?% reported having half to full time employment compared to 55 % and 43?% in the control group, respectively.

Results

On admission the control patients reported a median Oswestry disability index of 64?% and on recall the same of 64?%. The intervention group showed median Oswestry disability index estimates of 60 % and 66?%, respectively. The changes in the overall Oswestry disability index after 3 months differed significantly with an estimated 6?% for the intervention group versus 0?% for the control group (Wilcoxon p?=?0.050).

Conclusion

When combined with a multimodal inpatient lower back pain functional therapy in patients showing morphological degeneration, the mild hyperthermia therapy demonstrated statistically significant, although not clinically relevant benefits in comparison to the multimodal treatment alone. However, regarding the moderate overall patient-related benefits as measured in terms of the Oswestry disability index, the benefit of the underlying multimodal therapy concept implementation must be critically discussed irrespective of its combination with mild hyperthermia therapy.     

Über die Kombination von Morbus Basedowii mit Thymushyperplasie

Ohne Zusammenfassung     

über die Lachgasnarkose und besonders ihre Kombination mit der rektalen Avertinnarkose

Zusammenfassung Die rektale Avertinnarkose stellt zusammen mit der Stickoxydulsauerstoffnarkose eine glückliche Kombination dar. Die Nachteile des Avertins werden durch das Stickoxydul abgeschw?cht oder aufgehoben: Fortfall des psychischen Traumas, keine erhebliche Senkung des Blutdruckes, keine Erh?hung des Blutzuckers, keine Acetonausscheidung im Urin, keine Nierensch?digung, relativ rasches Erwachen aus der Narkose auch ohne CO₂-Atmung. Keinen Einflu\ hat das Verfahren auf die postoperative Thrombose und Embolie.     

Kontinuierliche Qualitätsverbesserung in der präklinischen Notfallmedizin

In this article the first implementation step of a quality management (QM) model for continuous quality improvement (CQI), in particular the PDCA cycle, by using the example of the Medical University Innsbruck emergency department and the Austrian Red Cross, Freiwillige Rettung (Voluntary Rescue) Innsbruck (FRI) is described. Using two questionnaires concerning personnel satisfaction main problem areas were identified and improvements suggested. The results serve to discuss whether the two organizations involved fulfil the necessary conditions for the QM approach of CQI.     

Über die Kombination der Avertinbasisnarkose mit Äther,Stickoxydul und Äthylen

Ohne Zusammenfassung Auszugsweise vorgetragen auf dem 10. internationalen Kongress für Narkose und An?sthesie in New York, 12–16. X. 31.     

Experimentelle Untersuchungen über die Behandlung des Wundstarrkrampfes mit einer Kombination von Curarin und Avertin

Ohne Zusammenfassung     

β-Blockade in the perioperative management of the patient with cardiac disease undergoing non-cardiac surgery

The cardiology literature has suggested for decades that β-blockade protects patients with ischaemic heart disease. Extending this concept to perioperative patients initially produced promising results, with reductions in perioperative myocardial ischaemia and longer-term cardiovascular complications observed in several small randomized trials. However, subsequent larger trials have either shown no benefit or greater morbidity (especially stroke), despite reductions in cardiovascular events. Retrospective database analyses have confirmed or disputed these findings. Speciality societies, most importantly, the American Heart Association/American College of Cardiology Foundation, have promulgated guidelines for perioperative β-blockade, which have been revised, as the evidence has changed. While the European guidelines continue to emphasize perioperative β-blockade in high-risk patients, the American guidelines have reduced the strength and breadth of recommendations, focusing on haemodynamic titration. Future work will need to focus on identifying populations most likely to benefit or to be harmed, including pharmacogenetic analyses and distinctions between individual β-blockers.     

Beobachtungen über die Verabreichung von organischen Kalksalzen in Kombination mit den Vitaminen B und D sowie C bei experimentellen Rippen-und Radius-Ulnafrakturen bei verschiedenen Kaninchenrassen

Ohne Zusammenfassung     

Die Kombination operativen und konservativen Vorgehens in der Behandlung von arteriellen Durchblutungsstörungen

Ohne Zusammenfassung     

Hypoparathyroidism in transfusion-dependent patients with β-thalassemia

Hypoparathyroidism is thought to be a rare consequence of iron overload seen in β-thalassemic transfused patients. This study was conducted to determine the prevalence of hypoparathyroidism in a large number of β-thalassemic patients, and its potential correlation with the presence of other endocrinopathies caused by iron overload. Serum and urine biochemical parameters were measured in 243 thalassemic patients (136 females and 107 males) in order to determine the prevalence of hypoparathyroidism and evaluate bone turnover. The patients were divided into two groups according to the presence of hypoparathyroidism. We compared the prevalence of other endocrinopathies and disease complications in the two groups. Hypoparathyroidism was detected in 13.5% of the patients (33 subjects; 17 males and 16 females). Serum-intact parathyroid hormone, and total and ionized calcium were significantly lower, while phosphorus was significantly higher in thalassemic patients with hypoparathyroidism. The reduction in BMD was more prominent in normal thalassemic patients (Z score = −2.246 ± 0.97) compared with those with hypoparathyroidism (Z score = −1.975 ± 0.89), although the difference was not statistically significant. Disturbed glucose metabolism was more common in patients with hypoparathyroidism (P < 0.05). In addition, heart dysfunction was statistically more frequent in this group (odds ratio = 2.51, P < 0.05). Hypoparathyroidism is a not infrequently observed complication in thalassemic patients. Since the concentration of ferritin is not a valuable tool in the prediction of the development of hypoparathyroidism, parathyroid function should be tested periodically, particularly when other iron overload-associated complications occur.     

Mechanisms of renal disease in β-thalassemia

Although advances in the care of patients with β-thalassemia translate into better patient survival, this success has allowed previously unrecognized complications to emerge, including several renal abnormalities. Clinical studies continue to show that mild tubular dysfunction and abnormalities in GFR are common in patients with β-thalassemia. Chronic anemia and iron overload are believed to lie behind these abnormalities. Nonprogressive increases in levels of serum creatinine have also been observed after exposure to some iron chelators. Longitudinal studies are needed to understand the true burden of renal dysfunction in patients with β-thalassemia.