Der Anaesthesist
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Due to the increasing age in western countries, combined with high rates of major surgical interventions in high-risk patients, perioperative reduction of cardiovascular complications becomes increasingly more important for perioperative physicians. After identifying patients with increased perioperative risk, specific interventions need to be considered to reduce their risk for cardiovascular complications, either by perioperative medical therapy or specific treatment options (e.g. coronary intervention). Several trials have demonstrated an effect of perioperative beta-blocker-therapy in reducing cardiovascular complications among high-risk patients. ⋯ Nevertheless, it remains unclear whether they are associated with a measurable improvement of outcome. Based on the ACC/AHA-guidelines, the present review describes a stepwise approach to surgical patients to identify perioperative risks, based on specific patient related risk factors, the kind of surgery and on the specific setting (emergency versus elective surgery). In addition, strategies to reduce perioperative cardiovascular complications are discussed.
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Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to today's numbers. This has a huge impact on the requirements for anaesthesiologic procedures. ⋯ A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.
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We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.
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Although scientific interest in the field of pain research is unremitting and the understanding of acute pain mechanisms has eminently advanced, it is evident that clinical practice of postoperative pain management still has major deficits. Indeed, the use of regional analgesia via a catheter, e.g. epidural analgesia (EDA), or patient controlled intravenous analgesia (PCIA) has become very popular. ⋯ However, the majority of patients are not managed by EDA or PCIA and cannot be ignored due to lack of knowledge of the proper use of basic analgesic treatment. Therefore, it makes sense to establish a standardized step-concept of postoperative pain management with regular quality control integrated into a multimodal perioperative rehabilitation program.
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In diabetics severe hyopotension can occur during anaesthesia as a consequence of cardiovascular autonomic neuropathy (CAN). A simple approach to recognize CAN is heart rate variability (HRV) measured at rest. The aim of this study was to determine the relationship between pre-operatively measured HRV and blood pressure stability during induction phase of anaesthesia. ⋯ The results confirm a significant relationship between HRV pre-operatively measured at rest and blood pressure stability during anaesthesia induction in diabetics. Particularly examination of CV, a simple test feasible within few minutes, may be useful in pre-operative risk stratification of these patients. Application of the time consuming traditional test combination to identify CAN seems to be unnecessary.