Der Anaesthesist
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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.
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The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation. ⋯ The demands of jurisdiction in terms of documentation of the positioning and of presentation of evidence are practically oriented and can basically be met. The same is true of the information supplied to the patient on the risk that positioning can cause harm. The doctor is obliged to supply evidence of the patient's substantive consent and the provision of information that this implies.
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Glucocorticoids are frequently used in clinical anaesthesiology and intensive care because of their antiallergic, antiinflammatory and antioedematous properties and anaphylactic reactions are rare. We report on a 62-year-old asthmatic patient with evidence of aspirin sensitivity. We administered 100 mg of hydrocortisone-21-hemisuccinate (Pharmacia & Upjohn, Erlangen, Germany) dissolved in 100 ml 0.9% sodium chloride solution for perioperative corticoid substitution. ⋯ He then developed atrioventricular block type III for which we transcutaneously paced the patient. Subsequently he was tested via skin prick tests, intracutaneous tests and i.v.-challenges resulting in the patient having positive reactions to hydrocortisone-21-hemisuccinate. Thus when allergic-like reactions result from glucocorticoid therapy one should consider corticoid allergy as a differential diagnosis.