Der Anaesthesist
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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.
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Due to the recent development in operative medicine medical and organizational demands on perioperative patient care have changed significantly. Corresponding to the responsibility of the operative colleagues for therapy of the primary disease, anesthesiologists have to account for monitoring and treatment of vital functions throughout the perioperative period, starting from preoperative evaluation until postoperative care. The postanesthesia recovery unit has a key role in perioperative management. ⋯ The terminology should be changed in the future in order to better characterize the new task spectrum, e.g. in perioperative anaesthetic care unit (PACU) for medical and medicolegal reasons patient security must have absolute priority above economic aspects. Effective postoperative pain control using epidural or patient-controlled intravenous analgesia may increase patient comfort and reduce postoperative complications caused by sympathoadrenergic activation. Both method can be safely used on normal wards provided that close cooperation and training of ward personnel is guaranteed as well as continuous supervision by a specialized acute pain service.
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Review
[Clinical studies on the peripheral effect of opioids following knee surgery. A literature review].
In this article 34 randomized controlled trials examining peripherally mediated opioid effects after knee surgery are discussed. All studies examined small doses of morphine injected intraarticularly at the end of knee surgery, but not all studies did show an analgesic effect of the peripheral opioid. Because of differing study designs a meta-analysis of the data is not possible. ⋯ But at least during the first two hours the effect is small or else doubtfull. Therefore a combination with bupivacain, a local anesthetic which acts rapidly but only for some hours can be recommended. Most authors testing this combination found it most useful.
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Besides other reasons, cost containments mandate the rational use of preoperative screening tests which should be adapted to the risk of the individual patient. Since the perioperative cardiac risk increases with age, elderly patients in particular require a thorough evaluation of their perioperative risk. Routine ECG, however, is not indicated in patients under 45 years of age who do not present with signs or history of preexisting cardiac diseases but should be performed on a routine basis in all patients over 45 years of age. ⋯ In patients whose perioperative cardiac risk as assessed clinically and by ECG is ambiguous, dipyridamole-thallium-myocardial scintigraphy (DTMS) and dobutamine-stress-echocardiography may contribute valuable information regarding the prediction of perioperative adverse cardiac events. In that respect, dobutamine-stress-echocardiography appears to be superior to DTMS. The laboratory tests required in patients of different ASA-risk groups and according to their age are presented in an overview.
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Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. ⋯ With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU.