Leitbild für die Leitstelle — Gefahren im Einsatz — Notfallmedizin im DRG-Zeitalter

Zusammenfassung Die 20. notfallmedizinische Jahrestagung der Arbeitsgemeinschaft Südwestdeutscher Notärzte (agswn) behandelte auch in diesem Jahr aktuelle berufspolitische Themen. Aktuelle Entwicklungen zur Verbesserung der Arbeitsabläufe in den Leitstellen wurden dargestellt, EDV-gestützte Systeme zur Notrufabfrage, die Vernetzung der Leitstellen und technische Verbesserungen der Leitstellensysteme genannt. Die Gefahren im Rettungsdienst waren ein weiterer Schwerpunkt der Tagung. Eine Ansteckungsgefahr bei Infektionstransporten bei MRSA-Patienten ist bei sachgemäßem Verhalten nicht zu befürchten. Weiterhin wurden die Möglichkeiten des terroristischen Einsatzes von biologischen Waffen realistisch deutlich relativiert. Amoklagen stellen dagegen eine nur schwer kalkulierbare Gefahrensituation dar. Als 3. Themenschwerpunkt wurden die besonderen Herausforderungen der Notfallmedizin im DRG-Zeitalter umrissen. Die Änderung des Einsatzspektrums und die Reduktion von Notarztstandorten erfordert die Bildung von Kompetenzzentren und eine hohe Qualifikation der Notärzte.     

Epidural Epinephrine and Clonidine: Segmental Analgesia and Effects on Different Pain Modalities

Background: It is not known whether epidural epinephrine has an analgesic effect per se. The segmental distribution of clonidine epidural analgesia and its effects on temporal summation and different types of noxious stimuli are unknown. The aim of this study was to clarify these issues.

Methods: Fifteen healthy volunteers received epidurally (L2-L3 or L3-L4) 20 ml of either epinephrine, 100 micro gram, in saline; clonidine, 8 micro gram/kg, in saline; or saline, 0.9%, alone, on three different days in a randomized, double-blind, cross-over fashion. Pain rating after electrical stimulation, pinprick, and cold perception were recorded on the dermatomes S1, L4, L1, T9, T6, T1, and forehead. Pressure pain tolerance threshold was recorded at S1, T6, and ear. Pain thresholds to single and repeated (temporal summation) electrical stimulation of the sural nerve were determined.

Results: Epinephrine significantly reduced sensitivity to pinprick at L1-L4-S1. Clonidine significantly decreased pain rating after electrical stimulation at L1-L4 and sensitivity to pinprick and cold at L1-L4-S1, increased pressure pain tolerance threshold at S1, and increased thresholds after single and repeated stimulation of the sural nerve.     

Patient-controlled intranasal analgesia: effective alternative to intravenous PCA for postoperative pain relief

PURPOSE: To investigate whether the nasal route for fentanyl administration in patient-controlled analgesia (PCA) provides as effective postoperative analgesia as intravenous PCA. METHODS: Patient-controlled intranasal or intravenous analgesia with fentanyl was investigated in 48 patients (ASA I-III) on the day of surgery (orthopedic, abdominal or thyroid) in a prospective, randomized, double-blind, double-dummy study. Fentanyl was given in a bolus of 25 microg for intranasal and 17.5 microg for i.v. PCA, lockout interval six minutes. The first requested dose was doubled in both groups. Pain intensity (101-point numerical rating scale) and vital parameters were observed at 11 measurement points during the 240 min study. Patients were asked for side effects at every measurement point and for their satisfaction at the end of the study by the same investigator (J.M.). RESULTS: Onset of analgesia, the first reduction in pain intensity on the numerical rating scale, was 21 +/- 11 min (range 15-45 min) in intranasal and 22 +/- 16 min (range 15-90 min) in i.v. PCA. Pain intensity was reduced from 55 +/- 11 to 11 +/- 10 in the intranasal group and from 53 +/- 8 to 11 +/- 6 in the i.v. PCA group. Vital parameters remained stable and side effects were comparable in both groups. The judgement "excellent" or "good" was given by 21 of 23 patients treated intranasally and 24 of 25 patients treated intravenously. CONCLUSION: Intranasal PCA with fentanyl was an effective alternative to i.v. PCA in postoperative patients.     

Continuous Spinal Anesthesia/Analgesia for Perioperative Management of Morbidly Obese Patients Undergoing Laparotomy for Gastroplastic Surgery

Background: The authors determined prospectively the safety of continuous spinal anesthesia combined with general anesthesia and the efficacy of postoperative pain relief with continuous spinal analgesia for morbidly obese patients undergoing vertical banded gastroplasty. Methods: 27 patients (13 men, 14 women) with a mean body mass index (BMI) of 50.4 ± 7.8 and several co-morbidities were studied. All patients were anesthetized with the same anesthetic regimen, which included midazolam, fentanyl, propofol, muscle relaxants, N₂O, isoflurane and intrathecal bupivacaine. Postoperative pain relief was provided for 5 days and all patients received the same regimen, which included intrathecal bupivacaine, fentanyl and intravenous tenoxicam. The intrathecal analgesic regimen was administered continuously through a pump which had the facility of providing bolus doses when requested in predetermined lockout intervals. Intra-operative monitoring included hemodynamic and respiratory parameters. Additional postoperative monitoring included respiratory rate, degree of sedation, sensory level of anesthesia, motor response and intensity of pain. Results: Intraoperative anesthetic technique was safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesia regimen provided effective analgesia in all patients.The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 postoperative hours were 14.1 ± 2.0 μg.h^-1 and 0.7 ± 0.1 mg.h^-1 respectively, while the requirements of anal gesia decreased progressively with time. The technique provided effective analgesia with low pain scores, which was reflected by ease in mobilizing and performing physical exercises with the physiotherapist. Only minor complications related to anesthesia and analgesia were encountered. Conclusion: To our knowledge, this technique of anesthesia and postoperative analgesia has not been described before in morbidly obese patients. This regimen merits further controlled trials to establish its place in the perioperative management of morbidly obese patients.     

Warum liegt der pH-Wert des Blutes bei 7,40?

Aim of the present paper is to discuss the physiologic principles of the acid-base status, in particular those of the pH value. The alpha-stat theory of acid-base management interprets the normal value of arterial pH, usually thought of as being 7.40, as a value derived from the intracellular pH, which is close to neutrality. This appears to have offered an evolutionary advantage, since most of the intermediates in biosynthetic pathways are ionized at neutrality resulting in a decreased rate of penetration across biological membranes of these compounds thus producing a benefit for the economy of a cell. Finally, we present the clinical implications of both the alpha-stat and the pH-stat strategy of acid-base management.     

Ischämischer Hirninfarkt und rupturiertes infrarenales Bauchaortenaneurysma

Zusammenfassung Eine 86-jährige Patientin mit Aphasie, linksseitiger Hemiparese und grenzwertig stabilem Kreislauf (Herzfrequenz 110/min, Blutdruck 110/60 mmHg) wurde vom Notarzt intubiert, mit 1.000 ml Kristalloiden behandelt und unter Verdacht auf einen Apoplex ins Krankenhaus eingeliefert. Bei der klinischen Untersuchung konnte ein pulsierender Bauchtumor palpiert werden. Die unverzüglich durchgeführte kranielle Computertomographie (CCT) schloss eine intrakranielle Blutung aus. Die Patientin entwickelte zunehmende Schockzeichen und eine Laktazidose. Die Abdomen-Sonographie bestätigte den Verdacht eines rupturierten infrarenalen Bauchaortenaneurysmas (BAA). Bei der Notfall-Laparotomie gelang ein Abklemmen der Aorta und eine Rohrprothese wurde eingebracht. Am Folgetag zeichnete sich in der CCT ein ischämischer Hirninfarkt im Stromgebiet der rechten A. cerebri media ab. Relevante Stenosen der extrakraniellen hirnversorgenden Arterien wurden duplexsonographisch ausgeschlossen. Der postoperative Verlauf war durch eine Langzeitbeatmung wegen rezidivierender Pleuraergüsse und einer Pneumonie mit schwieriger Entwöhnung vom Respirator gekennzeichnet. Am 52. Tag nach Aufnahme konnte die Patientin in eine Einrichtung zur neurologischen Frührehabilitation entlassen werden. Auch eine neurologische Herdsymptomatik muss, insbesondere bei gleichzeitiger Hypotonie, an systemische Ursachen, etwa an eine Anämie und Volumenmangel durch eine okkulte Blutung, denken lassen.

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The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro–con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.     

Indozyaningrün-Plasmaverschwinderate

Indocyanine green (ICG) is nearly exclusively eliminated from the blood by the liver and the ICG plasma disappearance rate (ICG-PDR) enables assessment of liver blood flow and function. The ICG-PDR which nowadays can be measured non-invasively by a transcutaneous system enables bedside and "on-line" regional monitoring in critically ill patients. So far, only complete lack of ICG-PDR as a sign of non-existing perfusion during liver transplantation has been reported. We describe two patients who developed mesenteric ischemia accompanied by an inadequate increase after revascularisation and an acute drop in the ICG-PDR. In both cases, a computed tomography scan was performed and confirmed an acute abdominal ischemia as indicated by ICG-PDR. Both patients suffered from occlusion of the truncus coeliacus while hepato-splanchnic perfusion via the A. mesenterica superior and the V. portae was maintained. ICG-PDR may be helpful for early detection of hepato-splanchnic ischemia and enables rapid and sufficient initiation of diagnostic and therapeutic procedures. In conclusion, ICG-PDR may be regarded as a clinically attractive bedside monitoring tool for early and reliable detection of partial ischemia in the hepato-splanchnic tract.