Der Anaesthesist
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During perioperative treatment of coagulopathic patients the so-called Point-of-Care (POC) analyses enable more rapidly available and more comprehensive hemostatic analyses compared to routinely performed conventional coagulation testing, such as activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen concentration and platelet count. In this review article a hemotherapy algorithm is presented which is based on viscoelastic and aggregometric POC measurements. The algorithm was designed double sided and consists of a general and a special part. ⋯ Reference values were defined for each parameter and therapeutic options are presented. In cases of persistent coagulopathy despite algorithm-conform therapy, the algorithm could be run through once again. Finally, the algorithm presents therapeutic options for an ultima ratio therapy approach.
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Conventional opioid therapy consists of the regular administration of extended-release opioids following fixed time intervals and, as needed, the supplemental use of an immediate-release formulation. For the patient needs of such rescue medication, recent studies distinguished different scenarios, such as an inadequate daily opioid dose or time interval (end-of-dose failure) from so-called breakthrough pain where the attacks can suddenly occur either spontaneously (idiopathic pain) or due to certain provocations (incident pain) despite optimal dose adjustment. ⋯ In these clinical trials the pain intensity and number of pain episodes were significantly reduced following transmucosal or intranasal fentanyl; however, the magnitude of these effects does not convincingly appear to be clinically relevant. Among other reasons this may be related to the fact that those patients who would perhaps benefit from such treatment have not yet been identified.
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Laryngeal mask insertion (LMI) represents a fundamental skill for anesthesiologists in routine management as well as in difficult airway situations. This study aimed to evaluate the time needed by first year anesthesiology residents to perform 40 LMIs and assessed the associated success rates and the number of attempts needed for successful LMI. ⋯ The increasing LMI success rate and the decreasing rate of LMI attempts for successful airway management correlated to a learning curve and development of LMI dexterity over time.
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Despite well-designed concepts of perioperative pain management, recent studies have revealed that a large number of patients still suffer from unacceptable pain after surgery. The purpose of this prospective evaluation was to critically analyze postoperative pain treatment provided by a routinely established, DIN certified acute pain service (APS) at the University Hospital Großhadern in Munich. ⋯ As described in many prospective studies, this evaluation revealed that for postoperative pain control, regional anesthesia is superior to intravenous patient-controlled analgesia with strong opioids in terms of analgesia and side effects. In the setting of a well-organized acute pain service with frequent education and training of all members involved, postoperative pain management is safe and effective. However, regular re-evaluation of the defined and certified procedures is necessary.
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Paravertebral blocks have experienced a renaissance because ultrasound-guidance is becoming common practice. The method is often presented as an alternative to thoracic epidural anaesthesia, mainly in the field of elective thoracic surgery. It is also propagated as an opioid-saving analgesic procedure in breast tumor surgery. ⋯ The absolute limit for medial needle advancement is the acoustic shadow of the transverse process. A catheter was placed 2 cm beyond the needle tip and its correct position was verified by hydrolocation. The excellent and continuous analgesia enabled non-invasive patient ventilation to be achieved directly after extubation and was continued for 6 days.