Der Anaesthesist
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Nutrition of intensive care patients is challenging due to complex metabolic changes. For this reason nutritional support adapted to the metabolic state is the only effective option to avoid hyperalimentation or hypoalimentation and thus has a direct influence on the prognosis. ⋯ Nowadays, most commercially available standard solutions are optimized concerning composition of nutrients; however, metabolic and gastrointestinal monitoring is recommended. In a selected group of patients the administration of immunomodulatory substances may be indicated but due to insufficient or conflicting study data an uncritical use of these supplements cannot be recommended.
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Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is a well-established strategy to prevent thrombotic complications in patients with acute coronary syndromes (ACS) and after percutaneous coronary interventions (PCI). Current practice guidelines for antiplatelet therapy advocate a 1 to 12-month dual antiplatelet therapy after bare metal stent PCI and an up to 12-month dual antiplatelet therapy after PCI in patients with ACS and drug-eluting stent PCI. ⋯ Based on the various available assays, the lack of validated cut-offs and the disappointing results of targeted antiplatelet therapy as demonstrated by the GRAVITAS trial, current guidelines of international societies recommend platelet function testing only for selected high risk patients despite the known association between clopidogrel low responsiveness and ischemic events. However, for individual patients taking clopidogrel, platelet function monitoring may be considered to safely shorten the preoperative waiting period, to assess the risk of bleeding and transfusion and to initiate specific therapy in bleeding patients.
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Editorial Case Reports
[Panta rhei : blood, professional career and anesthesiological self-conception].
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Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. ⋯ Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.
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Since October 2011 new guidelines exist for temperature management in critical care. According to the guidelines the term targeted temperature management (TTM) should replace the term therapeutic hypothermia. There is now a strong recommendation for TTM using 32-34°C as the preferred treatment for out-of-hospital adult cardiac arrest with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation. A TTM of 32.5-35.5°C is also recommended for the treatment of term newborns who sustain asphyxia and exhibit acidosis and/or encephalopathy.