Der Anaesthesist
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The case presented describes the combined onset of heparin-induced thrombocytopenia II (HIT) and post-transfusion purpura (PTP) 5-10 days following exposure to heparin and blood transfusion during aortic dissection repair. On day 4 the platelet count decreased by 40% and D-dimers started to increase again. Despite a low clinical probability for HIT-II at this time (4T score of 3) serological testing was done the next day and yielded a negative test result. ⋯ Careful evaluation of the time-related magnitude in platelet decrease, patient history, course of D-dimers, screening ultrasonography and ROTEM® seem to be helpful to initiate early appropriate therapy before serological test results become available. In contrast to the Clauss method of fibrinogen measurement, assessment of clot firmness in ROTEM® is not influenced by argatroban. Moreover, ROTEM® reveals the compensatory effects of increased functional fibrinogen on clot firmness during severe thrombocytopenia as an important variable for anticoagulation therapy during thrombocytopenia with increased thromboembolic risk.
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Surgical replacement of aortic valves is the gold standard for therapy of high grade aortic valve stenosis. However, the changes in demography confront the responsible medical discipline with an increasingly higher risk profile of patients which necessitates the development of new less invasive alternative forms of treatment for the surgical therapy of aortic valve stenosis. This developmental process has progressed from mini-thoracotomy to transcatheter aortic valve implantation (TAVI). ⋯ Because TAVI can be carried out while the heart is still beating and without a sternotomy or heart-lung maschine, this procedure is particularly suitable for elderly multimorbid patients and/or patients with previous cardiac surgery. The initial results of large prospective multicenter studies underline the value of TAVI in the modern treatment of high risk patients with symptomatic aortic valve stenosis. In addition to an understanding of the surgical procedure, anesthetists must have precise knowledge of the perioperative anesthesia management and possible complications of the procedure.
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In a medical liability process a medical expert takes on an outstanding position. He is the one process participant who preprograms the decision of the judge. However, he does not as such have an independent investigative competence and must understand his role as being an accessory to the judge. ⋯ In contrast the procedure in criminal processes follows the principle of official investigation and the absolute principle of in dubio pro reo. From this it follows that the evidence of causality must be proven with a probability close to certainty. Advice for the construction of expert opinion statements can be found in this article.
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Airway management is a core task for anesthesiologists. Deficiencies in training or equipment as well as fateful complications in this field are responsible for a significant proportion of anesthesia-associated morbidity and mortality. ⋯ Nevertheless, the "cannot intubate cannot ventilate scenario" still occurs and regularly results in poor outcome, such as permanent neurological deficits or even death. Therefore, awake fiberoptic intubation remains the gold standard in the expected difficult airway because when applied correctly this technique never leads to a point where a patient's respiration is compromised as a result of medical measures before a secure airway has been established.
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Neuraxial anesthesia is an established and safe procedure in perioperative pain therapy which can help to minimize complications and to improve perioperative outcome. In patients with acquired bleeding disorders by comorbidities or concomitant antithrombotic medication an individual decision should be made based on risks and benefits. A large number of literature references and guidelines help making a decision, for example the recently updated evidence-based guidelines of the American Society of Regional Anesthesia and Pain Medicine for patients receiving antithrombotic or thrombolytic therapy. ⋯ Evidence-based recommendations for neuraxial anaesthesia in patients with hemophilia, vWD or ITP cannot be offered. Each patient has to be treated individually with appropriate caution. This overview is intended to assist in the decision for or against neuraxial anesthesia in these patients, with emphasis on the pathophysiological background, blood investigations and case reports from the literature.