Der Sinn ungerichteter Reihenuntersuchungen, sogenannter Screening-untersuchungen, als Ergänzung zur präanästhetischen Untersuchung wird sowohl in Human- als auch Veterinärmedizin kontrovers diskutiert. Ziel dieser Arbeit war es, den Nutzen von Blutuntersuchungen beim Hund im Sinne eines ungerichteten Screenings zu prüfen. Bei 1537 Hunden wurde im Routinebetrieb der Klinik vor jeder Narkose zunächst eine standardisierte Anamnese erhoben und eine standardisierte klinische Untersu-chung durchgeführt. Im Anschluss hieran wurden Blutproben für die Untersuchung verschiedener Parameter des Blutbildes und der Blutchemie entnommen. 1123 Pati-enten wurden präanästhetisch vom Anästhesisten als „benötigt keine Laboruntersu-chung“ eingestuft. Diese Patientengruppe hätte ein ungerichtetes präanästhetisches Laborscreening betroffen und wurde für die Auswertung der Blutuntersuchung herangezogen. Der Anteile der Werte, die außerhalb des jeweiligen Referenzbereichs lagen, schwankte je nach Parameter zwischen 2 und 85 Prozent. Insgesamt wurden für die einzelnen Parameter deutlich mehr Abweichungen festgestellt als in vergleichbaren humanmedizinischen Studien. Der Anteil geringgradiger Abweichungen war hierbei sehr hoch. Aufregungsbedingte Blutbildveränderungen, Vorbehandlungen, der verwendete Referenzbereich und bei sehr jungen Hunden altersbedingte Abweichungen kamen als mögliche Ursachen für diese Veränderungen in Betracht. In elf Prozent der Fälle ließen sich deutliche Abweichungen einzelner Laborparameter vom Referenzbereich feststellen, die retrospektiv zu einer Neueinschätzung des jeweiligen Narkoserisikos beim Patienten führten. Hieraus hätte sich für 6,5 % aller Patienten eine Änderung im perioperativen Management ergeben. In humanmedizinischen Studien liegt der Anteil der Patienten, bei denen ein Laborscreening eine Änderung des Narkosemanagements ergeben hätte bei unter einem Prozent. Verschiedene spezifisch veterinärmedizinische Gründe werden für diese Diskrepanz vermutet. Aufgrund der Besitzeranamnese statt Patientenanamnese und aufgrund verschiedener Störfaktoren für die klinische Untersuchung wie Aufregung oder mangelnde Kooperationsbereitschaft des Patienten kann von einem höheren Prozentsatz nicht erfasster Patienten mit höhe-rem Narkoserisiko ausgegangen werden. Bezüglich aller untersuchten Patienten konnte ein deutlicher Einfluss des Alters auf die Risikoeinschätzung des Anästhesisten festgestellt werden. Eine Untersuchung auf Korrelationen zwischen Laborwerten und dem Alter der Tiere zeigte im Falle von Thrombozytenzahl, ALAT, Natriumkonzentration und Gesamteiweißkonzentration eine positive Korrelation zum Alter, im Falle der Glukose eine negative Korrelation. Der Einfluss des Alters auf die Laborparameter ist aber in allen Fällen zu gering ausgeprägt um für die Beurteilung der Laborparameter hinsichtlich einer Narkoserelevanz entscheidend zu sein. Die Altersstruktur der „laborauffälligen“ Patienten weist im Vergleich zu den „laborunauffälligen“ Patienten keinen statistisch sicherbaren Unterschied auf. Der Einfluss verschiedener Rassen auf die Variabilität der Laborparameter wurde anhand der Korrelation von Körpermasse und Laborparametern näherungsweise untersucht. Nur für Kreatinin konnte ein deutlicher Zusammenhang zwischen Kör-permasse und Laborwert festgestellt werden, was wahrscheinlich auf die unter-schiedliche Bemuskelung kleiner und großer Hunde, bezogen auf das Körperge-wicht, zurückzuführen ist. Für die Laborwertinterpretation relevante rassebedingte Unterschiede konnten jedoch nicht ausgemacht werden. Zusammenfassend zeigen die Ergebnisse dieser Studie deutliche Unterschiede zu denen vergleichbarer Humanmedizinischer Studien. Es können mittels eines unge-richteten Laborscreenings deutlich mehr relevante Laborwertveränderungen festge-stellt werden, die auch zu einer Neueinschätzung der Risikosituation für den Patienten führen können. Ein Einfluss des Alters auf die Zahl der Laborwertveränderungen konnte im Rahmen dieser Studie nicht festgestellt bzw. statistisch gesichert werden. Insgesamt zeigt der Anteil relevanter Laborwertveränderungen, dass präanästhetische Blutuntersuchungen beim Hund eine sinnvolle Ergänzung zur präanästhetischen Untersuchung darstellen können.

This thesis is concerned with comparing the education of nurses working in intensive care in the Czech and Slovak Republics. In the theoretical part of the thesis there are described the options for nursing education in anaesthesia, resuscitation and intensive care, both in the past and at present. Presented here is the comparison of the Czech and Slovak educational system, regulation of education, their similarities and differences. The aim of the empirical part is to find out what kind of education are nurses working with in the intensive care, what is their motivation to further education and to look at the current possibilities of nursing education in anaesthesia, resuscitation and intensive care in the Slovak and Czech Republic. To obtain the data for answers to these and other questions the questionnaire has been used; specifically the methods of quantitative research. The results are processed in tables and graphs. Keywords: History of nursing education, Specialized education, Anaesthesiology, Resuscitation and Intensive Care, Regulation, Slovak Republic, Czech Republic

<p>Cardiac arrest results in immediate interruption of blood flow. The primary goal of cardiopulmonary resuscitation (CPR) is to re-establish blood flow and hence oxygen delivery to the vital organs. This thesis describes different pharmacological interventions aimed at increasing cerebral blood flow during CPR and after restoration of spontaneous circulation (ROSC).</p><p>In a porcine model of cardiac arrest, continuous infusion of adrenaline generated higher cortical cerebral blood flow during CPR as compared to bolus administration of adrenaline. While bolus doses resulted in temporary peaks in cerebral blood flow, continuous infusion led to a sustained increase in this flow.</p><p>Administration of vasopressin resulted in higher cortical cerebral blood flow and a lower cerebral oxygen extraction ratio as compared to continuous infusion of adrenaline during CPR. In addition, vasopressin generated higher coronary perfusion pressure during CPR and increased the likelihood of achieving ROSC.</p><p>Parameters of coagulation and inflammation were measured after successful resuscitation from cardiac arrest. Immediately after ROSC, thrombin-antithrombin complex, a marker of thrombin generation, was elevated and eicosanoid levels were increased, indicating activation of coagulation and inflammation after ROSC. The thrombin generation was accompanied by a reduction in antithrombin. In addition, there was substantial haemoconcentration in the initial period after ROSC.</p><p>By administration of antithrombin during CPR, supraphysiological levels of antithrombin were achieved. However, antithrombin administration did not increase cerebral circulation or reduce reperfusion injury, as measured by cortical cerebral blood flow, cerebral oxygen extraction and levels of eicosanoids, after ROSC. </p><p>In a clinical study, the adrenaline dose interval was found to be longer than recommended in the majority of cases of cardiac arrest. Thus, the adherence to recommended guidelines regarding the adrenaline dose interval seems to be poor. </p>

<p>Evaluating respiratory mechanics during dynamic conditions without interrupting ongoing ventilation and flow, adds to the information obtained from the mechanics derived from static (= no flow) conditions, i.e., the flow signal has the potential to provide information on the properties of the respiratory system (including the tubing system). Hence monitoring the changes in the flow signal during ongoing mechanical ventilation would give information about the dynamic mechanics of the respiratory system. Any change in the mechanics of the respiratory system including the endotracheal tube (ETT) and the ventilatory circuit would affect the shape of the flow signal. </p><p>Knowledge of the airway pressure distal to the ETT at the carina level (= tracheal pressure) is required for calculating the extra resistive load exerted by the endotracheal tube in order to compensate for it. In a porcine model, the flow signal was used to non-invasively calculate tracheal pressure. There was good agreement between calculated and measured tracheal pressure with different modes of ventilation. However, calculation of tracheal pressure assumes that the inner diameter of the ETT is known, and this assumption is not met if the inner diameter is narrowed by secretions. Flow that passes a narrowed tube is decelerated and this is most pronounced with the high flow of early expiration, yielding a typical time constant over expiratory volume pattern that is easy to recognize during mechanical ventilation. This pattern reliably detected partial endotracheal obstruction during volume and pressure controlled mechanical ventilation. </p><p>A change in compliance of the respiratory system modifies the elastic recoil and this also affects the rate of the expiratory flow and the shape of its signal. In a porcine model, lung volume gains on the flow signal generated by the heartbeats (cardiogenic oscillations) provided information about the compliance of the respiratory system during ongoing mechanical ventilation</p><p>In conclusion analyzing the flow signal during ongoing ventilation can be a cheap, non-invasive and reliable tool to monitor the elastic and resistive properties of the respiratory system including the endotracheal tube.</p>

<p>Many elderly undergo cardiac surgery. The prevalence of malnutrition in elderly is high and increases with comorbidity. This thesis aims to clarify some aspects on performing surgery in elderly concerning nutritional status, nutritional treatment and age-related physiology.</p><p>Study I: 886 patients were assessed preoperatively by body mass index (BMI) and S-albumin and postoperatively for mortality and morbidity.. Low BMI increased the relative hazard for death and low S-albumin increased the risk for infection. BMI and S-albumin are useful in preoperative evaluations</p><p>Study II: we followed energy intake in 31 patients for five postoperative days. Scheduled and unscheduled surgery did not differ in preoperative resting energy expenditure (REE). REE increased by 10-12% postoperatively, more in unscheduled CABG. Nutritional supplementation increased total energy intake. All patients exhibited postoperative energy deficits, less prominent in the supplemented group. There were no differences in protein synthesis or muscle degradation. </p><p>Study III: in 16 patients, .we measured stress hormones and insulin resistance before surgery and for five postoperative days Patients were insulin resistant on the first two days. We saw no clearly adverse or beneficial effects of oral carbohydrate on insulin resistance or stress hormone response. </p><p>Study IV: 73 patients, with early enteral nutrition (EN), were observed until discharge or resumed oral nutrition. EN started within three days in most patients. In a minority, problems occurred (gastric residual volumes, tube dislocation, vomiting, diarrhoea, aspiration pneumonia). In the cardiothoracic ICU individually adjusted early EN is feasible. </p><p>Study V: in 16 patients, splanchnic blood flow (SBF) enhancing treatments (dopexamine (Dpx) or EN) were compared. Dpx increased systemic blood flow, but had only a transient effect on SBF. EN had no effect on systemic blood flow or SBF. Neither Dpx, EN or the combined treatment, exhibited any difference between groups on systemic or splanchnic VO₂ or oxygen extraction ratio. </p>

Cardiac arrest results in immediate interruption of blood flow. The primary goal of cardiopulmonary resuscitation (CPR) is to re-establish blood flow and hence oxygen delivery to the vital organs. This thesis describes different pharmacological interventions aimed at increasing cerebral blood flow during CPR and after restoration of spontaneous circulation (ROSC). In a porcine model of cardiac arrest, continuous infusion of adrenaline generated higher cortical cerebral blood flow during CPR as compared to bolus administration of adrenaline. While bolus doses resulted in temporary peaks in cerebral blood flow, continuous infusion led to a sustained increase in this flow. Administration of vasopressin resulted in higher cortical cerebral blood flow and a lower cerebral oxygen extraction ratio as compared to continuous infusion of adrenaline during CPR. In addition, vasopressin generated higher coronary perfusion pressure during CPR and increased the likelihood of achieving ROSC. Parameters of coagulation and inflammation were measured after successful resuscitation from cardiac arrest. Immediately after ROSC, thrombin-antithrombin complex, a marker of thrombin generation, was elevated and eicosanoid levels were increased, indicating activation of coagulation and inflammation after ROSC. The thrombin generation was accompanied by a reduction in antithrombin. In addition, there was substantial haemoconcentration in the initial period after ROSC. By administration of antithrombin during CPR, supraphysiological levels of antithrombin were achieved. However, antithrombin administration did not increase cerebral circulation or reduce reperfusion injury, as measured by cortical cerebral blood flow, cerebral oxygen extraction and levels of eicosanoids, after ROSC. In a clinical study, the adrenaline dose interval was found to be longer than recommended in the majority of cases of cardiac arrest. Thus, the adherence to recommended guidelines regarding the adrenaline dose interval seems to be poor.

Evaluating respiratory mechanics during dynamic conditions without interrupting ongoing ventilation and flow, adds to the information obtained from the mechanics derived from static (= no flow) conditions, i.e., the flow signal has the potential to provide information on the properties of the respiratory system (including the tubing system). Hence monitoring the changes in the flow signal during ongoing mechanical ventilation would give information about the dynamic mechanics of the respiratory system. Any change in the mechanics of the respiratory system including the endotracheal tube (ETT) and the ventilatory circuit would affect the shape of the flow signal. Knowledge of the airway pressure distal to the ETT at the carina level (= tracheal pressure) is required for calculating the extra resistive load exerted by the endotracheal tube in order to compensate for it. In a porcine model, the flow signal was used to non-invasively calculate tracheal pressure. There was good agreement between calculated and measured tracheal pressure with different modes of ventilation. However, calculation of tracheal pressure assumes that the inner diameter of the ETT is known, and this assumption is not met if the inner diameter is narrowed by secretions. Flow that passes a narrowed tube is decelerated and this is most pronounced with the high flow of early expiration, yielding a typical time constant over expiratory volume pattern that is easy to recognize during mechanical ventilation. This pattern reliably detected partial endotracheal obstruction during volume and pressure controlled mechanical ventilation. A change in compliance of the respiratory system modifies the elastic recoil and this also affects the rate of the expiratory flow and the shape of its signal. In a porcine model, lung volume gains on the flow signal generated by the heartbeats (cardiogenic oscillations) provided information about the compliance of the respiratory system during ongoing mechanical ventilation In conclusion analyzing the flow signal during ongoing ventilation can be a cheap, non-invasive and reliable tool to monitor the elastic and resistive properties of the respiratory system including the endotracheal tube.

Many elderly undergo cardiac surgery. The prevalence of malnutrition in elderly is high and increases with comorbidity. This thesis aims to clarify some aspects on performing surgery in elderly concerning nutritional status, nutritional treatment and age-related physiology. Study I: 886 patients were assessed preoperatively by body mass index (BMI) and S-albumin and postoperatively for mortality and morbidity.. Low BMI increased the relative hazard for death and low S-albumin increased the risk for infection. BMI and S-albumin are useful in preoperative evaluations Study II: we followed energy intake in 31 patients for five postoperative days. Scheduled and unscheduled surgery did not differ in preoperative resting energy expenditure (REE). REE increased by 10-12% postoperatively, more in unscheduled CABG. Nutritional supplementation increased total energy intake. All patients exhibited postoperative energy deficits, less prominent in the supplemented group. There were no differences in protein synthesis or muscle degradation. Study III: in 16 patients, .we measured stress hormones and insulin resistance before surgery and for five postoperative days Patients were insulin resistant on the first two days. We saw no clearly adverse or beneficial effects of oral carbohydrate on insulin resistance or stress hormone response. Study IV: 73 patients, with early enteral nutrition (EN), were observed until discharge or resumed oral nutrition. EN started within three days in most patients. In a minority, problems occurred (gastric residual volumes, tube dislocation, vomiting, diarrhoea, aspiration pneumonia). In the cardiothoracic ICU individually adjusted early EN is feasible. Study V: in 16 patients, splanchnic blood flow (SBF) enhancing treatments (dopexamine (Dpx) or EN) were compared. Dpx increased systemic blood flow, but had only a transient effect on SBF. EN had no effect on systemic blood flow or SBF. Neither Dpx, EN or the combined treatment, exhibited any difference between groups on systemic or splanchnic VO2 or oxygen extraction ratio.

Activation of spinal N-methyl-D-aspartate (NMDA) receptors stimulates cyclooxygenase and nitric oxide pathways. Compounds that block the activity of these NMDA receptor systems reduce pain hypersensitivity. However, their usefulness is limited by the side effects they produce. One way of reducing side effects is by combining drugs that produce the same overt effect by different mechanisms, which hopefully increase the net effect. In these series of studies, drugs that interact with NMDA receptor systems and their combinations were screened in vitro to identify spinal antinociceptive synergistic combinations that could be assessed in vivo. Based on developmental changes in thresholds, conduction velocities and blocking actions of the local anaesthetic lignocaine in neonatal rat L4/L5 dorsal root potentials, it was decided to use spinal cord in vitro preparation from 5- to 7-day-old rat pups. In single drug studies, the NMDA receptor channel blocker ketamine (1-50 µM) and the non-steroidal anti-inflammatory drug (NSAID) ketoprofen (200-600 µM), but not the NSAID salicylate (1000 µM) and the nitric oxide synthase inhibitor Nω-nitro-L-arginine methyl ester (L-NAME; 1-100 µM), reduced spinal NMDA receptor-mediated transmission. Ketamine also depressed non-NMDA receptor-mediated transmission. Using isobolographic and composite additive line analyses, fixed-ratio combinations of ketamine and ketoprofen, ketamine and L-NAME, and ketopofen and L-NAME synergistically depressed NMDA receptor-mediated transmission. The two former combinations had a subadditive effect on non-NMDA receptor-mediated transmission, and the latter had no significant effect. These studies identified that all combinations synergistically reduced both nociceptive transmission and potential side effects. In free-moving sheep implanted with indwelling cervical intrathecal catheters, 100 µ1 subdural administration of ketamine (25-400 µM) and ketoprofen (200-3200 µM) alone and in a fixed-ratio combination (873.95-3350.78 µM, 0.045:0.955) did not raise nociceptive thresholds as assessed by mechanical stimulation of one foreleg. Subdural administration of NMDA (2 mM) decreased mechanical nociceptive thresholds, and this was prevented by the highest concentrations of ketamine and ketoprofen alone and in combination. These findings demonstrated that NMDA receptor channel blockers and NSAIDs alone or in combination had no direct hypoalgesic effects when given onto the spinal cord of sheep, but they prevented NMDA-induced pain hypersensitivity. Simultaneous blockade of NMDA receptor systems could have important clinical implications.

<p>Systemic infection, major surgery, trauma and many other causes can lead to impaired organ function. Compensated shock is not detected by global hemodynamic and oxygen measurements, as they take no account for regional variations. Focus has therefore gradually turned from looking at systemic changes to selective investigations of regional blood flow and ischemia. This thesis presents a series of experiments evaluating new application and validation of various monitoring techniques.</p><p>An experimental porcine model with anesthetized and invasively monitored animals was used. The circulatory interventions included endotoxin infusion (septic shock), aortic constriction and selective clamping of splanchnic arteries. The aim was to compare air with saline tonometry, to validate the intraperitoneal use of tonometry and to reexamine the use of endoluminal reflectance pulse oxymetry. To investigate the relative contributions of regional blood flow and detection of ischemia, measurements of hepatic venous oxygen saturation (ShvO₂), lactate concentrations and PCO₂ gap were used.</p><p>Our findings support the use of air instead of saline as the preferred technique for tonometric measurements. With the intraperitoneal application of tonometry we gain more information on regional aspects of the splanchnic circulation, and it appears to be a reliable monitoring option for early detection of ischemia in the small intestine. Measurements of ShvO₂will give an overall reflection of the intestinal circulation. The sigmoid colonic pulse oximetry showed a non-linear response in relation to regional blood flow, and will therefore not be able to detect gradual changes in oxygen saturation. Determination of the regional to endtidal PCO₂ gap might prove valuable for monitoring of the intestinal circulation.</p><p>Because of sophisticated interactions between portal and hepatic arterial blood flow and hepatic compensation for regional ischemia, a combination of monitoring techniques might be needed. The results of this study will hopefully encourage clinical evaluation of intraperitoneal tonometry and endtidal PCO₂ gap recordings for non-invasive, semi-continuous, trend monitoring of the splanchnic circulation.</p>