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Schlusspunkte der Reihe „Medikamente zur intravenosen Narkoseinduktion“ bilden Ketamin und Midazolam. Beide konnen als Monotherapeutikum angewendet werden; dies ist in praxi aber unublich. Ihre Monogabe ist auf wenige sehr spezielle Indikationen und klinische Situationen beschrankt. Haufiger finden sich Kombinationen von Ketamin und Midazolam bzw. mit einer der Alternativen Propofol, den Barbituraten und Etomidat. Ursachlich sind Wirkungen und Nebenwirkungen beider Substanzen, deren positive Eigenschaften eher als Supplement zur Geltung kommen. Im abschliesenden Vergleich werden die behandelten Induktionshypnotika einander gegenubergestellt. Der Einsatz in bestimmten klinischen Konstellationen und bei speziellen Patientengruppen wird fur jedes einzelne Praparat bewertet. Es wird hervorgehoben, welches Medikament in welcher Situation am sinnvollsten erscheint. Da Methohexital mittlerweile in sehr wenigen klinischen Situationen verabreicht wird, wird bei der vergleichenden Bewertung auf diese Substanz verzichtet.

The direct oral anticoagulants (DOACs) present a valid therapeutic alternative to vitamin K antagonists in patients with non-valvular atrial fibrillation, for the prevention of venous thromboembolism, and for the treatment and prevention of the recurrence of pulmonary embolisms and deep vein thrombosis. Despite Idarucizumab as an antagonist of Dabigatran there are no other specific antidotes available yet. Therefore, perioperative coagulation management by DOACs is challenging in patients undergoing emergency surgical procedures with a high risk of bleeding complications. This case study describes the perioperative procedure during ascending aorta replacement after aortic dissection with apixaban administration.

Ketamine and midazolam form the endpoint of a series of articles about intravenous induction of anesthesia . Both substances can be used as single induction hypnotic drugs; however, in practice, this is unusual. Both substances, with the exception of a few very specific indications and clinical situations, are more frequently used in combination or with one of the more common alternatives propofol, barbiturates and etomidate. The reasons are the activity and side effects of both substances and their positive characteristics are used more as a supplement. In the concluding comparison the five discussed induction hypnotics are judged against each other. The use in certain clinical constellations and in special patient populations is evaluated individually for each substance. It is highlighted which drug appears most appropriate in which situation. As methohexital is nowadays only administered in very few clinical situations, this substance is not included in the comparative assessment.

The discovery of barbituric acid and research on its derivatives have long been of importance in advancements in modern anesthesia. Decades of clinical use of barbiturates worldwide and their abuse has led to an enormous amount of knowledge. Thiopental and methohexital are ultra-short acting derivatives of barbiturates. Their clinical application has been accompanied by an enormous increase in the knowledge of the pharmacology of cerebrally active drugs, in particular gamma-aminobutyric acid (GABA

In a series of articles dealing with hypnotics for induction of anesthesia, this article describes the development and current value of propofol. Its significance far exceeds that of a pure induction hypnotic (sedation in diagnostic and therapeutic procedures and on the intensive care unit). Propofol is also used for sedation in diagnostic and therapeutic procedures and on the intensive care unit. In the field of induction of anesthesia, the alternatives are barely used. Some contraindications are still controversial whereas others are no longer sufficiently anchored in the users' awareness (widespread off-label use). Adverse effects, such as injection pain, infection risk and propofol-related infusion syndrome (PRIS) could be significantly reduced by pharmacovigilance. With appropriate caution nearly the whole spectrum of anesthesiology patients can be treated using propofol. The hemodynamic side effects and the rare but potentially fatal PRIS are limitations. Further developments address the water solubility and the solubilizing agents of propofol.

Im Rahmen einer Serie zu den Induktionshypnotika werden im Folgenden Entwicklung und aktueller Stellenwert von Propofol behandelt. Seine Bedeutung geht weit uber die eines reinen Induktionshypnotikums hinaus (Sedierung bei diagnostischen und therapeutischen Prozeduren sowie auf der Intensivstation). Im Bereich der Narkoseinduktion werden Alternativen kaum noch eingesetzt. Manche Kontraindikationen werden weiterhin kontrovers diskutiert, wahrend andere den Anwendern wenig bewusst sind (verbreiteter „off label use“). Nebenwirkungen wie Injektionsschmerz, Infektionsrisiko oder Propofolinfusionssyndrom (PRIS) konnten durch Pharmakovigilanz verringert werden. Bei entsprechender Vorsicht kann nahezu das gesamte anasthesiologische Patientenspektrum mit Propofol behandelt werden. Hamodynamische Nebenwirkungen und das seltene, aber potenziell letal verlaufende PRIS stellen relevante Limitationen dar. Weiterentwicklungen adressieren die Wasserloslichkeit und den Losungsvermittler von Propofol.

The pharmacological and historical knowledge about the currently available intravenous induction hypnotics form the basis for the daily work of anesthetists. Side effects of using hypnotic induction agents must be anticipated and adequately treated. Decades of experience with using intravenous induction hypnotics have led to theoretical requirements for an ideal narcotic agent with a best possible side effect profile. In the absence of this optimal hypnotic induction agent, a careful selection of one or a combination of narcotic drugs is necessary to meet the needs of the respective risk constellation of the patient. While propofol enjoyed increasing frequency of use over the last three decades and is currently regarded as the gold standard in numerous clinics, thiopental is a noteworthy alternative apart from its elimination kinetics. Furthermore, substances with favorable hemodynamic profiles are available with etomidate and ketamine. Midazolam as a short-acting benzodiazepine rounds off the spectrum.

Das pharmakologische Wissen um die derzeit verfugbaren i.v.-Induktionshypnotika bildet die Grundlage der taglichen Arbeit des Anasthesisten. Nebenwirkungen ihres Gebrauchs mussen antizipiert und adaquat behandelt werden. Jahrzehntelange Erfahrungen haben zu theoretischen Anforderungen an das ideale Narkosemittel mit bestmoglichem Nebenwirkungsprofil gefuhrt. In Ermangelung dieses optimalen Induktionshypnotikums bedarf es der wohlbedachten Auswahl eines oder einer Kombination von Narkosemitteln, um der jeweiligen Risikokonstellation des Patienten gerecht zu werden. Wahrend sich Propofol uber die vergangenen 3 Dekaden zunehmender Anwendungshaufigkeit erfreut und in zahlreichen Kliniken als „Goldstandard“ gilt, findet sich mit Thiopental, abgesehen von dessen Eliminationskinetik, eine beachtenswerte Alternative. Ferner stehen mit Etomidat und Ketamin Substanzen mit gunstigem hamodynamischen Profil zur Verfugung. Midazolam als kurz wirksames Benzodiazepin rundet das Spektrum ab.

The direct oral anticoagulants (DOACs) present a valid therapeutic alternative to vitamin K antagonists in patients with non-valvular atrial fibrillation, for the prevention of venous thromboembolism, and for the treatment and prevention of the recurrence of pulmonary embolisms and deep vein thrombosis. Despite Idarucizumab as an antagonist of Dabigatran there are no other specific antidotes available yet. Therefore, perioperative coagulation management by DOACs is challenging in patients undergoing emergency surgical procedures with a high risk of bleeding complications. This case study describes the perioperative procedure during ascending aorta replacement after aortic dissection with apixaban administration.

Glycaemic control is another example of protocol-driven therapy in intensive care medicine to improve outcome in critically ill patients. While the advantage of this approach seems to be obvious, little is known about the problems of implementing such a protocol. The intention of this study was to evaluate problems of implementation and to develop strategies to overcome them.