[Spectrum of missions for a rescue helicopter. Changes in a south German urban area over the last 25 years]. / Einsatzspektrum eines Rettungshubschraubers. Veränderung in einem süddeutschen Ballungsgebiet in den letzten 25 Jahren.

BACKGROUND: Over the past decade the number of air rescue missions has increased continuously. The reasons for this are still discussed at great length. In addition to the demographic changes to becoming an increasingly older and sicker society, the political reform in the healthcare system with a simultaneous reduction and concentration of hospitals and formation of centers is also under discussion. AIM: The key questions to be answered are, therefore, can the increasing demands on the emergency physician really be explained by an increasing number of severely ill and injured patients? Is a proportion of the missions really not indicated because they do not involve immediately life-threatening "acute medical" emergencies and are caused by a lack of alternative paramedical service infrastructures, unavailability of a general practitioner or the only temporary availability of medical on-call standby services? MATERIAL AND METHODS: This study therefore analyzed the alterations of a possible change with respect to the spectrum of missions and the utilization of air rescue services in the metropolitan area of Stuttgart. All primary missions of the rescue helicopter (RTH) "Christoph 41" (based in Leonberg) from 2006 to 2011 were included in the study and compared to the data from 1987 to 1992. RESULTS: The indications for missions and the spectrum of patients for the RTH Christoph 41 have changed over the last 25 years. The proportion of emergency trauma cases has significantly decreased and missions for non-trauma cases have increased. The proportion of patients with life-threatening conditions has increased. Despite the change in the spectrum of missions, emergency physicians are confronted with a greater number of patients with life-threatening conditions than 25 years ago. The patients treated were on average clearly older than the patients who were treated by the air rescue service 25 years ago. CONCLUSION: The changes in the spectrum of missions up to more emergencies involving non-trauma patients and older patients must be taken into consideration during training and advanced training.

Friday night ventilation: a safety starting tool kit for mechanically ventilated patients.

We wish to report here a practical approach to an acute respiratory distress syndrome (ARDS) patient as devised by a group of intensivists with different expertise. The referral scenario is an intensive care unit of a Community Hospital with limited technology, where a young doctor, alone, must deal with this complicate syndrome during the night. The knowledge of pulse oximetry at room air and at 100% oxygen allows to estimate the PaO2 and the cause of hypoxemia, shunt vs. VA/Q maldistribution. The ARDS severity (mild [200

[Parkinson's disease. Perioperative management and anesthesia]. / Morbus Parkinson. Perioperatives Management und Anästhesie.

Approximately 10,000-15,000 Parkinson's disease (PD) patients per year undergo surgery in Germany. The demographic developments along with further surgical progress and procedural refinements will lead to increasing numbers of PD patients in the operating theatre (OR). There are several perioperative risk factors for PD patients, they more often require prolonged intensive care treatment and warrant particular anesthesiological attention with regard to the choice of drugs and equipment. Careful evaluation of concomitant diseases, maintenance of oral Parkinson therapeutic drugs up to the time of surgery and continuous perioperative dopaminergic therapy are key factors for reducing postoperative morbidity in PD patients undergoing surgery.

[Status asthmaticus. Role of extracorporeal lung assist procedures]. / Status asthmaticus. Stellenwert extrakorporaler Lungenunterstützungsverfahren.

The successful application of a pumpless extracorporeal lung assist procedure ("interventional lung assist, iLA) in three cases of severe refractory status asthmaticus, which could not be solved with conventional pharmacological and respiratory therapy is reported. After an individual risk-benefit analysis such a therapy can be used to reduce lung injury due to invasive mechanical ventilation. Because of the complexity of this therapy it should only be applied in special medical centers with sufficient experience in dealing with extracorporeal lung assist procedures.

[Perimortem semen retrieval from comatose intensive care patients : Medico-legal, psychological and ethical aspects]. / Perimortale Spermienentnahme bei komatösen Intensivpatienten : Medikolegale, psychologische und ethische Aspekte.

DEFINITION OF THE PROBLEM: Due to new technological advances in assisted reproduction, perimortem sperm retrieval has developed into a subject of increasing interest for families of comatose or dying male patients in critical care facilities. These requests raise a number of medical, ethical, legal and psychological issues. ARGUMENTS AND CONCLUSIONS: The case of a comatose dying male patient is used to illustrate the variety of positions and problems which have to be discussed. The importance of written consent of the donor, the interest of the unborn child and the legal limitations are highlighted.

[Intensive care patients. Determining daily energy expenditure - a comparison of two methods]. / Intensivmedizinische Patienten: Abschätzung des täglichen Energiebedarfs - Vergleich zweier Verfahren.

INTRODUCTION: Using indirect calorimetry (IC), required energy demand may be determined. The SenseWear (SW) armband uses skin temperature, galvanic skin response, heat flux, and a 2-axis accelerometer to estimate daily energy expenditure (EE). The aim of the present study was to evaluate accuracy of the SenseWear measurements in critically ill and ventilated patients. MATERIAL AND METHODS: After approval of the local ethics committee and written informed consent, critically ill and ventilated patients were enrolled. During a 24-h study period EE was continuously measured using the SW armband (standardized position at right upper arm); an IC was performed additionally. Measurement bias (DeltaEE) was calculated as DeltaEE=EE(SW)-EE(IC). Daily energy expenditure of both techniques (IC vs. SW) was compared using regression analysis and the Bland Altman method. The t-Test for paired samples was used for statistical analysis, p<0.05 was considered statistically significant. RESULTS AND DISCUSSION: In total, 23 critically ill and ventilated patients (17 male, 6 female; means: 59.9+/-17.3 years; body mass index 28.0+/-6.3 kg/m(-2)) were investigated. A mean bias of DeltaEE=-565.65+/-1,748.07 kJ (-135.0+/-417.2 kcal) [range: -4,709.56+/-2,224.89 kJ (-1,124 to +531 kcal); p=0.3547] was calculated. Bland-Altman analysis revealed that SW slightly overestimates IC energy expenditure for critically ill patients in the hypo- and normocaloric range [<7,123 kJ/24 h: DeltaEE=+644.42+/-1,038.70 kJ (<1,700 kcal/24 h: DeltaEE=+153.8+/-247.9 kcal); p=0.0838], but significantly underestimated IC values in the hypercaloric range [>10,056 kJ/24 h: DeltaEE=-2,679.09+/-1,698.63 kJ (>2,400 kcal/24 h: DeltaEE=-639.4+/-405.4 kcal); p=0.0098]. CONCLUSIONS: The SenseWear armband is non-invasive, convenient and easy to handle, but has a significant measurement bias in the hypercaloric range. Although IC is still best suited to determining metabolic need in intubated patients, measurements with the SenseWear armband provide significant advantages, e.g. in non-intubated patients, and give a fair estimation of daily energy expenditure when used alone.

Assessment of recovery, dreaming, hemodynamics, and satisfaction in postcardiac surgery patients receiving supplementary propofol sedation with S(+)-ketamine.

BACKGROUND: S(+)-ketamine is an analgesic and sedative drug with dissociative attributes. When it is used without sedatives, nightmares have been described. The aim of this study was to assess the effects of postoperative analgosedation with propofol and S(+)-ketamine when compared to standard propofol analgosedation in terms of recovery, dreaming, hemodynamics, and patient satisfaction. METHODS: Forty-eight patients were sedated with propofol (1-3 mg/kg/h) after coronary artery bypass grafting and allocated randomly on admission to the intensive care unit to receive either S(+)ketamine (2 mg mg/kg/h; group A) or 0.9% saline as a placebo (group B) in a double-blind fashion. If necessary, boli of 3.75 mg piritramide (an opioid) were given in both groups. RESULTS: Patients receiving S(+)-ketamine had significantly higher satisfaction for pain management (Visual Analog Scale [VAS] = group A: median 10 [range 9-10]; group B: median 9 [range 6-10]) despite their lower piritramide consumption. Patients receiving S(+)ketamine showed significantly faster eye opening (82+/-51 vs 156+/-110 min) but dreamed significantly more often (at 2 h, 67% in group A vs 29% in group B; at 24 h, 43% in group A vs 10% in group B), whereas no significant differences were detected in the incidence of nightmares at 2 h, 14% in group A vs 10% in group B; at 24 h, 5% in group A vs 5% in group B. CONCLUSIONS: Patients receiving S(+)-ketamine showed higher satisfaction for pain management and dreamed more often, but they did not have more nightmares.

[Early alterations in rat brain protein expression during sepsis]. / Frühzeitige Veränderungen der Proteinexpression im Gehirn der Ratte bei Sepsis.

INTRODUCTION: Sepsis still has a high mortality in critically-ill patients. Here, analysis of early alterations in cerebral proteome may lead to a better understanding of the molecular basis of cerebral dysfunction. The aim of the present study was therefore to analyze cerebral protein dynamics during emerging sepsis in an established rat model. MATERIAL AND METHODS: To induce sepsis, an established coecal ligature and double puncture (coecal ligature and puncture, CLP) model was used on Wistar rats. After 12 hours, surviving rats (sepsis: n=6 and sham: n=6) were decapitated and their brains prepared for gel electrophoresis (2DE) and subsequent mass spectrometry. Biological function of differentially regulated proteins (t-test, p<0.01) was then analyzed using bioinformatic network analysis (ingenuity pathways analysis, IPA). RESULTS: Mortality was 40 % in the sepsis-group and no rat of the sham-group died. Altogether, nine significantly regulated proteins were identified (4 up-regulated, 5 down-regulated). IPA then detected eight network proteins and interpreted them in the context of established protein alterations for sepsis. CONCLUSION: The combination of proteomics and IPA could identify proteins in rat brain, whose expression was significantly regulated during sepsis. The methodological approach applied in the present study may facilitate the quest for novel sepsis-induced protein alterations in the future.

Volatile anesthetics evoke prolonged changes in the proteome of the left ventricule myocardium: defining a molecular basis of cardioprotection?

BACKGROUND: Volatile anesthetics can alter cardiac gene and protein expression. Of those underlying molecular changes in gene and protein expression in the myocardium after exposure to volatile anesthetics that have been identified, some of them have been related to cardioprotection. METHODS: We used two-dimensional gel electrophoresis and mass spectrometry to identify changes in the protein expression of the left ventricle myocardium of anesthesized rats. We maintained anesthesia for 3 h using isoflurane, sevoflurane or desflurane, respectively, at 1.0 minimum alveolar concentration (MAC) and dissected the left ventricular myocardium either immediately or 72 h after the end of anesthesia. RESULTS: We found changes of at least twofold in 106 proteins of the more than 1.600 protein spots discriminated in each gel. These differentially expressed proteins are associated with functions in glycolysis, mitochondrial respiration and stress response. No obvious difference could be observed between the patterns of differential expression of the three volatile anesthetics. CONCLUSION: We provide the first study of post-anesthetic protein expression profiles associated with three common volatile anesthetics. These volatile anesthetics promote a distinct change in the myocardial protein expression profile, whereby changes in the expression pattern still exist 72 h after anesthesia. These proteome changes are closely related to cardioprotection and ischemic preconditioning, indicating a common functional signaling of volatile anesthestics.

[Anaesthesia in patients with Parkinson's disease]. / Anästhesie bei Patienten mit Parkinson-Erkrankung.

The neurodegenerative death of dopaminergic neurons of the pars compacta of the substantia nigra leads to the classical triad of resting tremor, muscle rigidity, and bradykinesia of Parkinson's disease. Parkinson's disease is a common disease of elderly patients requiring perioperative anaesthesia. Particular anaesthetic problems are neurological, respiratory, and cardiovascular. The clinical features and the interaction of common anaesthetics with the drug therapy of the patient present an anaesthetic challenge and directly influence perioperative morbidity and mortality.

Baroreflex sensitivity and heart rate variability in conscious rats with myocardial infarction.

The baroreflex sensitivity (BRS) and the heart rate variability (HRV) were studied in conscious rats after myocardial infarction (MI; induced by coronary artery ligation) and after sham operation (SH). BRS was determined by linear regression of R-R interval vs. arterial pressure changes induced by nitroprusside or methoxamine (intravenous bolus). HRV was calculated from 3-min electrocardiogram recordings. Left ventricular end-diastolic pressure and plasma atrial natriuretic peptide were increased after MI; plasma norepinephrine and basal heart rate (HR) remained unchanged. At 3 and 28 days after MI, BRS was reduced as indicated by decreased reflex bradycardia (RB) (MI, 0.66 +/- 0.13 and 0.78 +/- 0.07 ms/mmHg; SH, 1.27 +/- 0.16 and 1.48 +/- 0.14 ms/mmHg, respectively; P < 0.05 MI vs. SH). At 56 days after MI, BRS was normalized. RB was unaffected by atropine 3 and 28 days after MI but reduced in all other groups. The increase of basal HR by atropine 3 and 28 days after MI was less than in all other groups. HRV (SD of mean N-N interval, coefficient of variance, low- and high-frequency power; studied at 28 and 56 days) was similar in all groups. It is concluded that BRS is transiently depressed in rats with left ventricular dysfunction after MI probably due to a reduced reflex vagal activity. Even though basal HR and HRV are unchanged after MI, a temporary attenuation of tonic vagal activity is unmasked after autonomic blockade.