Der Anaesthesist
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Pain relief should be considered part of a multimodal postoperative approach. Combining patient-controlled pain therapy with other measures i.e. respiratory therapy or early mobilisation improves the outcome after surgery. In many patients adequate postoperative pain relief can be achieved by an optimal use of traditional pain management strategies. ⋯ Dosage of patient-controlled intravenous opioids or epidural drug combinations must be adjusted to the individual needs of the patients. Best results can only be achieved if the patient remains under observation by the pain service. This requires daily or twice daily rounds including an adequate documentation of pain relief, side effects and complications.
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The extent of myocardial damage occurring during acute myocardial infarction is time dependent, and there is abundant evidence from most clinical trials that mortality reduction is greatest in patients treated early with thrombolytic agents, although beneficial effects have been shown with treatment initiated up to 12 h after onset of symptoms. All studies on prehospital thrombolysis have conclusively shown the practicability and safety of patient selection and administration of the thrombolytic agent. The accuracy of diagnosis in the prehospital setting was comparable to trials of in-hospital thrombolysis, e.g., in the Myocardial Infarction Triage and Intervention Project (MITI) 98% of the patients enrolled had subsequent evidence of acute myocardial infarction. ⋯ The results of randomized studies comparing the results of prehospital and in-hospital thrombolysis seem to justify the prehospital institution of thrombolytic therapy, especially in rural areas where transport times to the hospital are long and the expected time gain is largest. The choice of the thrombolytic agent seems to be of minor importance and should follow prehospital practicability (bolus injection) and costs. Aspirin should be given to all prehospital patients with suspected myocardial infarction regardless of thrombolytic therapy.
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Case Reports
[Successful thrombolysis of a fulminant lung embolism during cardiopulmonary resuscitation].
A healthy 38-year-old woman suffered a sudden cardiac arrest 2 days after a vaginal hysterectomy. Although standard cardiac life support (CPR) was instituted immediately after the event, it was not possible to re-establish a spontaneous circulation for about 40 min. Systemic intravenous thrombolytic therapy with slow injection of 1.5 million IU urokinase was performed as a final life-maintaining measure because of the high probability that the underlying cause was a pulmonary embolus; 10 min later (after 60 min of ongoing CPR) the patient regained a stable circulation. She survived without neurological deficit in spite of the long duration of CPR.
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The shift of age distribution within the population of industrialized societies has led to an increased need of treating diseases in elderly patients and at the same time bearing an increased operative risk. Today, the development of surgical techniques and intensive care treatment enables us to carry out numerous procedures in geriatric patients. Innovative surgical techniques like minimal invasive surgery with minor trauma due to the surgical approach changed patient's categories, also. ⋯ Contrasting experiences made in most other countries and especially in the third world, in Germany economic restrictions have not been encountered as of yet. Economical conditions, an increase in surgical procedures in elderly patients and advances in medical science will continue to change the surgical patient's characteristics profoundly. From the physicians viewpoint we have actively participate in this development by personal interaction with the patient, by interdisciplinary cooperation and prompt social and political action.