Aneurysmatische Subarachnoidalblutung - Diagnostik und Therapie zerebraler und systemischer Komplikationen

Das Management der aneurysmatischen Subarachnoidalblutung (SAB) erfordert ein grundlegendes Verständnis der Erkrankung, ihrer Therapieoptionen und Komplikationen. Ziel der präoperativen Therapie ist das Verhindern einer Nachblutung durch Blutdruckkontrolle, die Behandlung von Schmerz und Unruhe sowie die Stabilisierung der Atem- und Kreislaufverhältnisse. Ein symptomatischer Hydrozephalus muss sofort behandelt werden. Die eigentliche Aneurysmatherapie erfolgt entweder durch mikrochirurgisches Clipping oder endovaskuläres Coiling. Das postoperative Ziel liegt neben der Optimierung der Atem- und Kreislaufverhältnisse vor allem in der Prophylaxe, Diagnostik und Therapie SAB-assoziierter zerebraler Komplikationen (zerebraler Vasospasmus, Hydrozephalus, Epilepsie) und systemischer Komplikationen (Elektrolytstörungen, kardiale Dysfunktion). Diese Arbeit gibt einen Überblick über das prä-, peri- und postoperative Management von Patienten mit SAB. ABSTRACT: The management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a fundamental knowledge of the disease, its therapeutic options and possible complications. The preoperative goal is to prevent rebleeding by controlling blood pressure and treating pain and anxiety as well as stabilizing cardiopulmonary functions. An acute hydrocephalus has to be treated immediately. Microsurgical clipping or endovascular coiling are the therapeutic options available. The postoperative goal aims at securing cardiopulmonary functions as well as recognizing and treating cerebral (cerebral vasospasm, hydrocephalus, epilepsy) and systemic complications (electrolyte disorder, cardiac dysfunction). This article provides an overview about the pre-, peri- and postoperative management of patients with SAH

The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study

In critically ill patients, many decisions depend on accurate assessment of the hemodynamic status. We evaluated the accuracy of physicians' conventional hemodynamic assessment and the impact that additional advanced monitoring had on therapeutic decisions. Physicians from seven European countries filled in a questionnaire in patients in whom advanced hemodynamic monitoring using transpulmonary thermodilution (PiCCO system; Pulsion Medical Systems SE, Feldkirchen, Germany) was going to be initialized as part of routine care. The collected information included the currently proposed therapeutic intervention(s) and a prediction of the expected transpulmonary thermodilution-derived variables. After transpulmonary thermodilution measurements, physicians recorded any changes that were eventually made in the original therapeutic plan. A total of 315 questionnaires pertaining to 206 patients were completed. The mean difference (±standard deviation; 95 % limits of agreement) between estimated and measured hemodynamic variables was -1.54 (±2.16; -5.77 to 2.69) L/min for the cardiac output (CO), -74 (±235; -536 to 387) mL/m(2) for the global end-diastolic volume index (GEDVI), and -0.5 (±5.2; -10.6 to 9.7) mL/kg for the extravascular lung water index (EVLWI). The percentage error for the CO, GEDVI, and EVLWI was 66, 64, and 95 %, respectively. In 54 % of cases physicians underestimated the actual CO by more than 20 %. The information provided by the additional advanced monitoring led 33, 22, 22, and 13 % of physicians to change their decisions about fluids, inotropes, vasoconstrictors, and diuretics, respectively. The limited clinical ability of physicians to correctly assess the hemodynamic status, and the significant impact that more physiological information has on major therapeutic decisions, support the use of advanced hemodynamic monitoring in critically ill patients

Mortality after surgery in Europe: a 7 day cohort study

Background: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.Methods: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher’s exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.Findings: We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9–3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19 1·05; p=0·06] for Finland to 6·92 [2·37–20·27; p=0·0004] for Poland).Interpretation: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.Funding: European Society of Intensive Care Medicine, European Society of Anaesthesiology