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Durch Staphylokokken hervorgerufene nosokomiale Infektionen haben nach wie vor eine grose Bedeutung fur Morbiditat und Mortalitat. Besonders die zunehmenden epidemischen Ausbruche mit dem methicillinresistenten Staphylococcus aureus, die damit verbundenen infektiologischen, therapeutischen und hygienischen Probleme sowie die daraus entstehenden Folgekosten stellen eine zunehmende Herausforderung fur Arzte, Pflegende, die Hygienekommissionen und Klinikleitungen dar.

To examine the influence of intra- and postoperative blood loss and operative trauma on erythropoietin (EPO) production we studied patients undergoing endoprosthetic surgery of the hip. Immunoreactive plasma EPO was determined in ten patients (seven male, three female, aged 39-68 years), undergoing surgery for hip arthroplasty (n = 8) or revision hip arthroplasty (n = 2). EPO levels had already been determined during preoperative autologous deposit, thus allowing direct comparison between EPO response to blood loss alone and the response to blood loss and operative trauma. Perioperative blood loss amounted to 1720 (480-8100) ml (median, range). The hemoglobin concentration decreased from 12.4 (10.6-14.0) g/dl (median, range) before the operation to 10.0 (9.3-12.3) g/dl 2 h after the operation. Thereafter, the hemoglobin concentration increased slowly due to transfusion and erythropoiesis and was not significantly different (p0.05) from the preoperative value on the seventh postoperative day. The EPO concentration was preoperatively 26 (11-28) mU/ml and increased 2 h after the end of the operation, reaching a peak of 64 (45-104) mU/ml at 24 h. This peak was followed by a plateau at lower, but still elevated levels. The EPO concentration remained significantly elevated above the preoperative value on the seventh postoperative day. Plasma EPO concentrations showed an adequate response to postoperative anemia compared with the time course after autologous donation. In the early postoperative phase, they do not seem to be appreciably influenced by the neuroendocrine response to trauma, by mediators of inflammation, or by the postoperative catabolic state. The slightly elevated EPO concentration in the late postoperative phase indicates that factors other than anemia may contribute to EPO production at this time.

Homologous transfusion is associated with infectious and immunological risks. Preoperative autologous deposit reduces homologous transfusion requirements considerably. Usually donations are carried out at weekly intervals. In this study we investigated the effect of shorter donation intervals on erythropoiesis and perioperative transfusion requirements. Methods. A total of 40 consecutive patients scheduled for hip arthroplasty and taking part in an autologous donation programme were randomly assigned to two groups: group I gave blood on day 0, 3, 7 (and 14), group II at weekly intervals. The aim was deposit of three blood units of 450 ml. A patient was deferred if hemoglobin concentration prior to donation fell below 11 g/dl, and in this case 100 mg Fe2+ three times daily was prescribed. Blood was stored with CPDA-1 anticoagulant. Surgery was performed between day 28 and 35. A perioperative hemoglobin concentration lower than 9 g/dl was considered a transfusion trigger. Results. Group I was made up of 21 patients (10 women, 11 men, aged 39 – 69 years) who gave blood at short intervals, and group II of 19 patients (10 women, 9 men, aged 37 – 77 years) who gave blood at weekly intervals. General data, calculated blood volume and erythrocyte mass prior to donation were comparable. Each patient donated three units. Four patients had to be deferred once, one in group I, three in group II. The hemoglobin concentration in group I decreased from 13.9±1.2 g/dl (x±SD) to 13.3±1.0 g/dl prior the operation, in group II from 13.5±1.3 g/dl to 12.5±1.1 g/dl. Preoperatively the hemoglobin concentrations differed significantly (P

Plasma immunoreactive erythropoietin (EPO) concentrations were studied in ten patients (7 men, 3 women) predonating autologous blood for hip arthroplasty. Donations were scheduled on day 1, 3, 7, 14 (and 21 if four units could not be donated previously). A predonation hemoglobin concentration of 11 g/dl was required. The donations led to a decline of the hemoglobin concentration from 14.1 +/- 1.0 g/dl (X +/- SD) prior to donation to 11.0 +/- 0.9 g/dl on day 15. EPO concentration prior to donation was 17.6 +/- 2.6 mU/ml. Each phlebotomy was followed by a rise in EPO levels that reached a peak concentration within 1 day. The highest concentration (35.8 +/- 15.0 mU/ml) was measured on day 16. The peak concentration was followed by a plateau at lower, although still elevated levels after the first and second donation, and by a slow, continuous decline after the third and fourth donation. This particular time course is similar to that during weekly donations [15]. The time integral of the EPO concentration during the first 3 weeks, however, was greater in the present study. This increased availability of EPO early during donation may lead to a more efficient stimulation of erythropoiesis.

The variations in plasma erythropoietin (EPO) concentration during preoperative deposit of autologous blood were studied in 12 patients (8 men, 4 women). Four donations were scheduled at weekly intervals. A predonation hemoglobin concentration of 11 g per dL (110 g/L) was required. Hemoglobin concentration decreased from 14.3 +/- 1.1 g per dL (143 +/- 11 g/L) (mean +/- SD) before the first donation to 11.7 +/- 0.7 g per dL (117 +/- 7 g/L) on Day 22 (p less than or equal to 0.0001). Reticulocyte counts increased from a median of 31,800 (range, 4900-95,000) per microL (median, 32 x 10(9)/L [range, 5-95 x 10(9)/L]) to 93,800 (16,800-194,900) per microL (median, 94 x 10(9)/L [range, 17-195 x 10(9)/L]) on Day 28 (p less than or equal to 0.01). Plasma EPO concentration was 17.8 +/- 5.1 mU per mL prior to the first donation and displayed a small and transient peak after each donation. A sustained elevation followed each peak. Although plasma EPO concentration differed significantly from the baseline value after the first donation, only the peak concentrations after the second (35.5 +/- 15.5 mU/mL), third (38.0 +/- 14.5 mU/mL), and fourth (36.1 +/- 11.0 mU/mL) donations exceeded the normal range. The moderate, biphasic increase in plasma EPO concentration and the moderate increase in erythropoiesis suggest two strategies in autologous blood donation that should be investigated with respect to efficiency and safety: 1) more aggressive donation schemes, which reduce donation intervals and/or the minimum hemoglobin concentration and 2) the administration of recombinant human EPO.

The intention of this work was to create a simple instrument for training in the operation of a lung ventilator and the understanding and interpretation of the lung-mechanical relationships between the flow and pressure curves produced by a ventilator in a patient's lung. The task was solved in a phragmatical way by storing respiratory curves in an 'acquisition' phase and reproducing them in the later 'stimulation' phase. The user can choose the following parameters: type of ventilation (flow control, pressure control, SIMV), inspiratory minute volume, inspiratory pressure, respiratory rate, percentage inspiratory time and PEEP.

Der in Abb. 15–1 gezeigte Fall 1 beschreibt die Beatmung eines beispielsweise infolge Sedation und Relaxation passiven Patienten. Wahrend der Inspiration insuffliert das Beatmungsgerat Atemgas in die Lungen des Patienten. Dadurch kommt es zu einem Ansteigen des Atemwegsdrucks (dunne Linie, am proximalen Tubusende gemessen) und des Trachealdrucks (fette Linie, am distalen Tubusende gemessen). Man beachte, dass der Trachealdruck nicht deckungsgleich mit dem Atemwegsdruck, sondern verzogert zu diesem ansteigt, sodass beide Druckkurven erst am Ende der Insufflationsphase auf gleichem Druckniveau verlaufen.

Die Idee der proportionalen Druckunterstutzung geht auf Versuche von Tyler u. Grape im Jahr 1962 zuruck. Spater haben verschiedene Autoren das Konzept in identischer oder abgeanderter Form wieder aufgenommen und dafur unterschiedliche Begriffe und Abkurzungen gepragt wie „negative impedance ventilation“(NIV), „negative ventilator resistance“(NVR), „negative ventilator compliance“(NVC).

Die zeitabhangigen Atemkurven sind wichtige Bausteine des respiratorischen Monitorings und sollten als primare Informationsquelle dienen. Trotzdem bleibt festzuhalten, dass je nach Atemmuster mitunter dramatische Veranderungen der atemmechanischen Eigenschaften kaum aus den zeitabhangigen Kurven herausgelesen werden konnen, weil sie sich — wie etwa im Fall der druckkontrollierten Beatmung — in einer veranderten Zeitkonstanten ausdrucken. Eine Veranderung der Zeitkonstanten beeinflusst zwar die Kurvenform, allerdings auf eine nicht ohne weiteres vom Auge auflosbare Weise. In diesem Kontext sind die Atemschleifen den Zeitkurven eindeutig uberlegen.

Abbildung 3-1 zeigt schematisch das respiratorische System eines mechanisch beatmeten Patienten. Das respiratorische System besteht aus 3 passiven und einem aktiven Subsystem. Im Hinblick auf ihren jeweiligen Gesamtwiderstand (Impedanz) umfassen die passiven Subsysteme: a) den respiratorischen Trakt (mit oberen und unteren Atemwegen) und das darin enthaltene Gasvolumen, b) das Alveolargewebe mit dem darin enthaltenen Gasvolumen und c) den Thorax (Brustkorb mit assoziierten Muskeln und Zwerchfell).

Das der volumengeregelten Beatmung zugrunde liegende Konzept wurde in Sektion II besprochen; deren typische Zeitkurven und Atemschleifen werden in der nachfolgenden Sektion IV, Kap. 17, gezeigt. An dieser Stelle wollen wir uns nur auf die Konstruktion der Druck-Volumen-Schleife aus der Druck-Zeit-Kurve und der Volumen-Zeit-Kurve beschranken. Da das Volumen durch Integration des Flusses gewonnen wird, kann anstelle der Volumen-Zeit-Kurve auch die Fluss-Zeit-Kurve verwendet werden, zumal die Fluss-Zeit-Kurve eine Standardkurve in der Beatmung darstellt.

In der medizinischen Diagnostik und in der klinischen Patientenuberwachung (Monitoring) ist es gangige Praxis, zeitlich veranderliche Messgrosen in Form von Kurven darzustellen. Dabei gibt die sich andernde Hohe der Kurve die zu jedem Zeitpunkt gemessene Grose des Signals wider. Mit moderner Computertechnik ist es ohne weiteres moglich, Kurven automatisch zu analysieren und besondere Punkte der Kurve, etwa die Maximaloder die Minimalwerte, als Zahlenwerte anzuzeigen.

Beim klassischen SIMV-Modus (s. Kap. 7.4; Abb. 10-1, 10-2) wird dem Patienten neben den volumengeregelten Atemzugen eine Spontanatmung wahrend der „Exspirationsphase“des Beatmungsgerates ermoglicht, wobei diese spontanen Atemzuge vom Beatmungsgerat nicht unterstutzt werden. Eine Erweiterung von SIMV stellt die Moglichkeit dar, die spontanen Atemzuge optional mit einer Druckassistenz zu unterstutzen. Die Druckassistenz besteht in einem druckgeregelten Verfahren und ist mit dem bei „pressure support ventilation“(s. Kap. 8.5) identisch.

Grundlage fur diesen Modus (Abb. 9-1) ist eine druckgeregelte Beatmung, bei der die Atemzuge entweder vom Beatmungsgerat zeitgesteuert ausgelost oder bei spontanen Inspirationsanstrengungen durch den Patienten getriggert werden konnen. Daneben mussen die Einstellungen fur eine volumengeregelte Beatmung, insbesondere die Atemfrequenz, das Atemhubvolumen und der inspiratorische Gasfluss vorgenommen werden.

Im Gebiet der klinischen Atemphysiologie ist das Messen respiratorischer Grosen eine Grundaufgabe und beinahe eine Selbstverstandlichkeit, uber die kaum nachgedacht wird. Der Wert der respiratorischen Diagnostik und die Qualitat der daraus abgeleiteten therapeutischen Masnahmen, namentlich der Einstellung der Beatmung, steht und fallt aber mit der Qualitat der Messung.

Bei der mechanischen Beatmung wird der konvektive Gastransport jeweils von Gasquellen gesteuert. Der Gasquelle kommen hierbei zwei Funktionen zu: 1. die Bereitstellung von Atemgas, 2. die Bereitstellung der physikalischen Energie fur den Gastransport.

70-jahriger Patient, KOF 1,98 m2, mit schwerer Exazerbation einer COPD. Untersuchung am 9. Tag nach Intubation.

64-jahriger Patient, KOF 2,02 m2, nach kardiogenem Schock und Reanimation. Untersuchung am 3. Tag nach Intubation.

Auch der nicht intensivmedizinisch tatige Anasthesist wird regelmasig mit der Betreuung von Intensivpatienten konfrontiert, wenn diese von ihm wahrend Transporten oder im OP versorgt werden.

Oesophageal malposition of an endotracheal tube is among the leading causes of anaesthesia incidents. While clinical manoeuvres for detection of tube malposition are unreliable, monitoring (i.e. capnography) can prevent such incidents. The problem is particularly important in prehospital care, where capnography is not (yet) widely available. We tested three devices used for differentiating oesophageal from endotracheal intubation: 1. Non-CO2-dependent Oesophageal Detector Device (ODD) as described by Pollard and Wee, 2. Semi-quantitative chemical disposable capnometer EasyCAP (Nellcor), 3. Non-quantitative infrared miniaturised capnometer MiniCAP (MSA). METHODS. 50 anaesthetised minipigs were intubated with a Magill tube. An identical additional tube was placed in the oesophagus. The cuffs of both tubes were inflated. Unexperienced personnel (students, laboratory technicians) were asked to determine the position of one of the tubes by using one of the devices according to the randomisation plan. The decision had to be taken within 30 s. Using the ODD, the proband first injected 100 ml air into the lung (or stomach) and then tried to aspirate the same volume. EasyCAP and MiniCAP were used according to manuals. RESULTS. Each device was used 25 times with a tracheal tube and 25 times with an oesophageal tube. All tube position identifications were correct. When ventilating the oesophagus/stomach for capnometric control, regurgitation into the tube occurred six times (five times with the EasyCAP and once with the MiniCAP). In these cases, the decision was based on this occurrence and not on the display of the device. While using the ODD no regurgitation occurred. CONCLUSION. These devices are useful for preclinical practice. According to the literature and our experience, the ODD is superior for the initial control of tube position, especially in cardiac arrest. Capnometry is needed, however, for continuous control of ventilation.

Die Dokumentation arztlichen Handelns und der Informationsaustausch innerhalb eines Krankenhauses zum Zwecke einer fachgerechten Patientenversorgung sind seit langem als notwendig anerkannt [2, 7, 12, 31, 41, 46, 63]. Insbesondere im Fach Anasthesiologie, das eine interdisziplinare und fachubergreifende Funktion hat, wird groser Wert auf eine moglichst exakte, umfassende und zeitgerechte Dokumentation gelegt. Dies ist unerlaslich, um die Kommunikation zwischen den unterschiedlichen Funktionsbereichen innerhalb eines Krankenhauses zu ermoglichen und die Auswirkungen der Anasthesie nachzuvollziehen. Das Anasthesie-verfahren selbst und dessen Dokumentation konnen fur den weiteren Krankheitsverlauf des Patienten entscheidend sein.

Die praoperative Eigenblutspende ist ein wirksames Verfahren zur Reduzierung des Fremdblutbedarfs in der elektiven Chirurgie [6, 7]. Mogliche Gefahren wie die Ubertragung von Infektionskrankheiten und immunologische Komplikationen werden dadurch gemindert.

Homologous transfusion is associated with infectious and immunological risks. Preoperative autologous deposit reduces homologous transfusion requirements considerably. Usually donations are carried out at weekly intervals. In this study we investigated the effect of shorter donation intervals on erythropoiesis and perioperative transfusion requirements. METHODS. A total of 40 consecutive patients scheduled for hip arthroplasty and taking part in an autologous donation programme were randomly assigned to two groups: group I gave blood on days 0, 3, 7 (and 14), group II at weekly intervals. The aim was deposit of three blood units of 450 ml. A patient was deferred if hemoglobin concentration prior to donation fell below 11 g/dl, and in this case 100 mg Fe 2+ three times daily was prescribed. Blood was stored with CP-DA-1 anticoagulant. Surgery was performed between day 28 and 35. A perioperative hemoglobin concentration lower than 9 g/dl was considered a transfusion trigger. RESULTS. Group I was made up of 21 patients (10 women, 11 men, aged 39-69 years) who gave blood at short intervals, and group II of 19 patients (10 women, 9 men, aged 37-77 years) who gave blood at weekly intervals. General data, calculated blood volume and erythrocyte mass prior to donation were comparable. Each patient donated three units. Four patients had to be deferred once, one in group I, three in group II. The hemoglobin concentration in group I decreased from 13.9 +/- 1.2 g/dl (mean +/- SD) to 13.3 +/- 1.0 g/dl prior the operation, in group II from 13.5 +/- 1.3 g/dl to 12.5 +/- 1.1 g/dl. Preoperatively the hemoglobin concentrations differed significantly (P0.05), as did calculated erythrocyte mass (1633 versus 1474 ml, P0.05). Reticulocytes increased from 46 x 10(3)/microliters (median) to a maximum of 94 x 10(3)/microliters on day 7 in group I, and from 44 x 10(3)/microliters to 108 x 10(3)/microliters in group II on day 14. Serum ferritin decreased from 122 micrograms/l (median) to 82 micrograms/l in group I, and from 140 micrograms/l to 77 micrograms/l in group II. These parameters did not differ statistically between the two groups. Intra- and postoperative blood loss amounted to 2175 ml (median) in group I versus 1430 ml in group II (P0.05). The perioperative hemoglobin concentration was similar in the two groups. Homologous transfusion requirements were similar in the two groups (1 unit in group I, vs 3 units in one patient and 1 unit in two patients in group II). CONCLUSIONS. Short donation intervals resulted in a higher preoperative erythrocyte mass after similar preoperative deposit, and significantly higher blood loss was tolerated with similar homologous transfusion volume.

Die Notwendigkeit der Dokumentation aller arztlichen Tatigkeiten ist seit langem anerkannt. Dies gilt im besonderen auch fur die Durchfuhrung eines Anasthesieverfahrens [1, 5, 10, 25, 33, 36, 50].

Sowohl beim inner- als auch interklinischen Transport von Notfall- und Intensivpatienten kommt es auf die sichere, luckenlose Weiterfuhrung der bisherigen Therapie ohne Qualitatsverlust hinsichtlich Monitoring und Betreuung an. Weil sich jedoch beide Transportverfahren in ihrem Anforderungsprofil deutlich unterscheiden, werden sie getrennt dargestellt.

The preliminary results of a multicenter study designed to determine the utility of the processed EEG in combination with heart rate and blood pressure for estimating anesthetic depth are reported. The study is planned to include 1,000 ASA I, II, and III patients undergoing surgery with at least a 60-minute duration of anesthesia. The preliminary results indicate that the use of EEG and clinical signs may provide better control of anesthetic depth. The study design provides ideal conditions for determining whether spectral edge frequency is a useful criterion for management of routine general anesthesia in a typical clinical environment.