Der Anaesthesist
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Review Meta Analysis
[Update on preemptive analgesia : Options and limits of preoperative pain therapy.]
Wall created the term preemptive analgesia in 1988 and in doing so set in motion a movement to prevent acute and chronic postsurgical pain. The concept of preemptive analgesia implies the administration of analgesic drugs or an intervention before a surgical procedure. A preemptive analgesic approach can comprise non-steroidal anti-inflammatory drugs (NSAID) and cyclo-oxygenase-2 inhibitors (coxibs) used to decrease the production of prostaglandins, local anesthetics (e.g. epidural) to reduce nociceptive input to the spinal cord as well as opioids, N-methyl-D-aspartate (NMDA) antagonists, antidepressants and anticonvulsants, all of which have an inhibitory influence on the central nervous system. ⋯ Reduction of chronic postoperative pain is an important medical function which is also justified from socioeconomic perspectives. Future studies should combine several procedures for perioperative pain therapy in order to do justice to the multifactorial aspects of pain chronification and should also be planned over a sufficiently long observation time period.
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The effect of muscle relaxants varies among people and the extent, the duration and recovery from the neuromuscular block varies. Clinical tests cannot determine the effect of muscle relaxants which is only possible with neuromuscular monitoring. The relaxometry procedure measures the muscular response to electrical stimulation of the corresponding motor nerve and the adductor pollicis muscle is mostly used; however, this muscle is not representative for other muscle groups, such as the muscles of the larynx and diaphragm. ⋯ The train of four (TOF) is used at the beginning of surgery for monitoring of the optimal time for tracheal intubation; moreover, the TOF is used during surgery for monitoring of the muscle blockade and at the end of surgery for monitoring recovery. Monitoring of deep muscular blockades, however, is only possible with the posttetanic count (PTC) when there are no TOF counts. The PTC allows repetition and higher doses of muscle relaxants during abdominal surgery; therefore, conditions for surgery are optimal and cumulation of muscle relaxants is avoided.
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Practice Guideline Guideline
[Practice Guidelines for Management of the Difficult Airway : Update by the American Society of Anesthesiologists Task Force.]
In February 2013 the Committee of the American Society of Anesthesiologists (ASA) Task Force published the amended version of the "Practice guidelines for management of the difficult airway" which replace the recommendations from 2003. The amended version re-evaluated the recommendations from 2003 in 2011, evaluated recently published studies and recommendations and included them in the new practice guidelines. ⋯ In short, the current guidelines basically correspond to the previous version published 10 years ago but are, however, more than twice as extensive. This article summarizes and comments on the cornerstones of the guidelines.
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Since ancient times poisoning has been treated medicinally. Clinical toxicology, in the narrow sense of the term, developed from the foundation of specialized medical treatment units for poisoning and the formation of the first poison information centers in the second half of the twentieth century. Historically, the first poison information centers were often localized at pediatric clinics or departments of internal medicine. It became increasingly more obvious that this pooling of competences made sense. ⋯ In all, even questionable cases of poisoning consultation at emergency poison centers is recommended. An extensive list of all German speaking poison information centers is available on the homepage of GIZ-Nord (http://www.giz-nord.de).
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Comparative Study
[Postoperative pain management after minimally invasive hysterectomy : Thoracic epidural analgesia versus intravenous patient-controlled analgesia.]
In view of the development of innovative and non-traumatic surgical techniques, postoperative pain management should be carried out depending on the invasiveness of the intervention. In the present study two analgesic strategies were compared in patients undergoing minimally invasive hysterectomy: epidural analgesia (EDA) and intravenous patient-controlled analgesia (iv-PCA). ⋯ To reduce the number of patients suffering from postoperative pain a procedure-specific pain management should be developed. The results of this study have shown that even in minimally invasive surgery, such as vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy there are some advantages for epidural analgesia compared to intravenous patient-controlled analgesia. In particular reduced pain intensity, lower need for analgesics and reduced occurrence of PONV can lead to excellent patient comfort, fast recovery as well as positive effects on health-related quality of life. However, there are also some disadvantages such as an increased rate of urinary retention and restriction of mobility.