Der Anaesthesist
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Review Randomized Controlled Trial Comparative Study Clinical Trial
[Continuous peridural analgesia vs patient - controlled intravenous analgesia for pain therapy after thoracotomy].
Continuous epidural analgesia (EA) and patient-controlled intravenous analgesia (PCA) are widely used for postoperative pain control. Studies indicate that both analgesic regimens provide good analgesia after major surgery. However, because of the following reasons it is still unclear whether one of the two modes of application is superior. First, there are conflicting data regarding the differences in pain relief and drug use between epidural and intravenous administration of opioids. Second, in many studies epidural analgesia is performed by a combination of local anaesthetics and opioids. Third, reduced morbidity was observed only in some of the studies, in which epidural analgesia provided better pain relief than systemic opioid supply. Despite these conflicting results, EA with local anaesthetics and fentanyl as well as PCA with piritramid, a highly potent mu-agonist, are routinely used in Germany. The purpose of this study was to compare these two treatments for analgesic efficacy, pulmonary function, incidence of side effects and complications in patients undergoing thoracotomy. ⋯ In this study EA with local anaesthetics and fentanyl provided superior postoperative pain control and a lower incidence of sedation and nausea compared to intravenous PCA with piritramid, but there was no superiority as to pulmonary complications and duration of hospital stay.
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In the early post-traumatic period severe traumatic brain injuries and massive bleeding from disrupted parenchymal organs, large vessels or crush injuries of the pelvis may present as morphological damage that renders survival impossible, although aggressive fluid and blood replacement therapy in conjunction with immediately stopping blood loss surgically may result in survival in selected cases. In contrast, late mortality from multiple organ failure - which in the past limited survival in 10 to 30% of patients in that condition - has in recent years reduced this as the cause of death to less than 5%. ⋯ A threat to optimal care of the severely injured patient may arise from the economical restraints imposed on health-care providers. When one considers the enormous political and socioeconomical importance of rehabilitating the predominantly young trauma patients and reintegrating them into the work world, an appeal has to be made to all those responsible to secure optimal care for severely injured patients in the future.