Vasopressin als Reservevasopressor: Behandlung ausgewählter kardiogener Schockzustände

Zusammenfassung: Der vasodilatorische Schock ist die häufigste Schockform des Intensivpatienten. Als Folge übermäßiger und prolongierter Mediatorproduktion kann der vasodilatorische Schock auch aus primär nichtvasodilatorischen Schockzuständen (z.B. kardiogener oder hypovolämer Schock) entstehen. Eine zusätzliche Infusion mit Arginin Vasopressin (AVP) zeigte vorteilhafte Effekte auf die Hämodynamik und wahrscheinlich auch das Outcome bei Patienten mit vasodilatorischem Schock durch Sepsis oder nach großen chirurgischen Eingriffen. In dieser Fallsammlung wird über die erfolgreiche Anwendung von AVP bei drei chirurgischen Intensivpatienten mit primär kardiogenen Schockzuständen berichtet. Die hämodynamischen Effekte von AVP waren den im septischen Schock berichteten AVP-induzierten Veränderungen sehr ähnlich. Diese scheinen auch bei den beschriebenen Patienten maßgeblich durch die potente Vasokonstriktion sowie die ermöglichte Reduktion hoher, potenziell toxischer Katecholamindosierungen bedingt zu sein. Dabei dürfte gerade die AVP-vermittelte Reduktion der Herzfrequenz und der pulmonalarteriellen Drücke bei Patienten mit eingeschränkter kardialer Funktion von Vorteil sei

Ten Years of Experience Training Non-Physician Anesthesia Providers in Haiti.

Surgery is increasingly recognized as an effective means of treating a proportion of the global burden of disease, especially in resource-limited countries. Often non-physicians, such as nurses, provide the majority of anesthesia; however, their training and formal supervision is often of low priority or even non-existent. To increase the number of safe anesthesia providers in Haiti, Médecins Sans Frontières has trained nurse anesthetists (NAs) for over 10 years. This article describes the challenges, outcomes, and future directions of this training program. From 1998 to 2008, 24 students graduated. Nineteen (79%) continue to work as NAs in Haiti and 5 (21%) have emigrated. In 2008, NAs were critical in providing anesthesia during a post-hurricane emergency where they performed 330 procedures. Mortality was 0.3% and not associated with lack of anesthesiologist supervision. The completion rate of this training program was high and the majority of graduates continue to work as nurse anesthetists in Haiti. Successful training requires a setting with a sufficient volume and diversity of operations, appropriate anesthesia equipment, a structured and comprehensive training program, and recognition of the training program by the national ministry of health and relevant professional bodies. Preliminary outcomes support findings elsewhere that NAs can be a safe and effective alternative where anesthesiologists are scarce. Training non-physician anesthetists is a feasible and important way to scale up surgical services resource limited settings

Job satisfaction among anesthetists in Ethiopia-a national cross-sectional study

Background Ethiopia has substantially increased production of associate clinician anesthetists. This study aimed to determine the level of and factors that predict job satisfaction among a national sample of anesthetists. Methods A cross-sectional study conducted in 2014 sampled 252 anesthetists. Respondents rated 37 items related to job satisfaction and working and living conditions using a Likert scale, which ranged from 1 (strongly disagree) to 5 (strongly agree). Univariate and multivariable logistic regressions were used to determine factors associated with the main outcome variable, level of job satisfaction. Adjusted odds ratios and 95% confidence intervals were calculated to show the magnitude of associations. Results Less than half (n = 107, 42.5%) of anesthetists were satisfied with their job. Work environment (aOR = 1.87, 95% CI = 1.06, 3.31) and more than 10 years of experience working in the public health system (aOR = 4.96, 95% CI = 1.11, 22.13) were predictors of job satisfaction in the multivariable model. Conclusion Ethiopian anesthetists have low levels of job satisfaction, with work environment and years of experience being factors that predict their satisfaction positively. Motivation and retention of this cadre will require emphasis on creating a safe and conducive work environment, and interventions designed to motivate junior anesthetists

Critical care resources in the Solomon Islands: a cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>There are minimal data available on critical care case-mix, care processes and outcomes in lower and middle income countries (LMICs). The objectives of this paper were to gather data in the Solomon Islands in order to gain a better understanding of common presentations of critical illness, available hospital resources, and what resources would be helpful in improving the care of these patients in the future.</p> <p>Methods</p> <p>This study used a mixed methods approach, including a cross sectional survey of respondents' opinions regarding critical care needs, ethnographic information and qualitative data.</p> <p>Results</p> <p>The four most common conditions leading to critical illness in the Solomon Islands are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis. Complications of surgery and trauma less frequently result in critical illness. Respondents emphasised the need for basic critical care resources in LMICs, including equipment such as oximeters and oxygen concentrators; greater access to medications and blood products; laboratory services; staff education; and the need for at least one national critical care facility.</p> <p>Conclusions</p> <p>A large degree of critical illness in LMICs is likely due to inadequate resources for primary prevention and healthcare; however, for patients who fall through the net of prevention, there may be simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality. Emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment, to prevent critical care from unduly diverting resources away from other important parts of the health system.</p

Emergency and critical care services in Tanzania: a survey of ten hospitals.

While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty. Ten hospitals in four regions of Tanzania were assessed using a structured data collection tool. Quality was evaluated with standards developed from the literature and expert opinion. Important deficits were identified in infrastructure, routines and training. Only 30% of the hospitals had an emergency room for adult and paediatric patients. None of the seven district and regional hospitals had a triage area or intensive care unit for adults. Only 40% of the hospitals had formal systems for adult triage and in less than one third were critically ill patients seen by clinicians more than once daily. In 80% of the hospitals there were no staff trained in adult triage or critical care. In contrast, a majority of equipment and drugs necessary for emergency and critical care were available in the hospitals (median 90% and 100% respectively. The referral/private hospitals tended to have a greater overall availability of resources (median 89.7%) than district/regional hospitals (median 70.6). Many of the structures necessary for Emergency and Critical Care are lacking in hospitals in Tanzania. Particular weaknesses are infrastructure, routines and training, whereas the availability of drugs and equipment is generally good. Policies to improve hospital systems for the care of emergency and critically ill patients should be prioritised

Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices

BACKGROUND. The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis. METHODS. A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects. RESULTS. Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries. CONCLUSIONS. This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries

Comparison of the temporal release pattern of copeptin with conventional biomarkers in acute myocardial infarction

Background Early detection of acute myocardial infarction (AMI) using cardiac biomarkers of myocardial necrosis remains limited since these biomarkers do not rise within the first hours from onset of AMI. We aimed to compare the temporal release pattern of the C-terminal portion of provasopressin (copeptin) with conventional cardiac biomarkers, including creatine kinase isoenzyme (CK-MB), cardiac troponin T (cTnT), and high-sensitivity cTnT (hs-cTnT), in patients with ST-elevation AMI. Methods We included 145 patients undergoing successful primary percutaneous coronary intervention (PCI) for a first ST-elevation AMI presenting within 12 h of symptom onset. Blood samples were taken on admission and at four time points within the first 24 h after PCI. Results In contrast to all other markers, copeptin levels were already elevated on admission and were higher with a shorter time from symptom onset to reperfusion and lower systolic blood pressure. Copeptin levels peaked immediately after symptom onset at a maximum of 249 pmol/L and normalized within 10 h. In contrast, CK-MB, cTnT, and hs-cTnT peaked after 14 h from symptom onset at a maximum of 275 U/L, 5.75 lg/L, and 4.16 lg/L, respectively, and decreased more gradually. Conclusions Copeptin has a distinct release pattern in patients with ST-elevation AMI, peaking within the first hour after symptom onset before conventional cardiac biomarkers and falling to normal ranges within the first day. Further studies are required to determine the exact role of copeptin in AMI suspects presenting within the first hours after symptom onset

Year in review in Intensive Care Medicine 2009: II. Neurology, cardiovascular, experimental, pharmacology and sedation, communication and teaching

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