Der Anaesthesist
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This paper reviews the pathophysiological processes occurring after contact of blood with artificial surfaces during continuous haemofiltration and the predominant role of platelets in the genesis of extracorporeal thrombosis. A basic prerequisite for effective renal replacement therapy is adequate anticoagulation in order to inhibit activation of coagulation and to avoid haemofilter clotting. Antithrombotic regimens controlling plasma coagulation activation and platelet-surface interactions, as well as methods of coagulation monitoring are reviewed. ⋯ Heparinoids and hirudine are indicated in patients with heparin-induced thrombocytopenia II. In patients at risk for thromboembolism, regional citrate anticoagulation may be beneficial. Performing continuous haemofiltration without antithrombotic therapy is not recommended.
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The risks and benefits of epinephrine given during cardiopulmonary resuscitation (CPR) are controversially discussed. Animal experiments revealed beta-receptor-mediated adverse effects of epinephrine such as increased myocardial oxygen consumption, ventricular arrhythmia, ventilation-perfusion defects, and cardiac failure in the postresuscitation phase. In clinical studies, high-dose vs. standard-dose epinephrine was unable to improve resuscitation success. ⋯ For CPR of adults with shock-refractory ventricular fibrillation, 40 units AVP or 1 mg epinephrine is recommended (class 2B); patients with asystole or pulseless electrical activity should be resuscitated with epinephrine. AVP is not recommended for adult cardiac arrest patients with asystole or pulseless electrical activity; or pediatric cardiac arrest patients due to a lack of clinical data. Until definitive data about AVP vs. epinephrine effects during CPR are available, the present state of knowledge should be interpreted that two vasopressors are available for use instead of one.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Postoperative pain therapy in minimally invasive direct coronary arterial bypass surgery. I.v. opioid patient-controlled analgesia versus intercostal block].
Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. ⋯ ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.