Der Anaesthesist
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Although dehydration is a serious condition associated with significant morbidity and mortality in palliative care patients, as in any other patient group, treatment remains controversial. A narrative review of the causes of dehydration during end of life was conducted paying special attention to the nature of terminal dehydration. ⋯ The following inferences can be derived: 1) the available evidence does not support a clear decision in favor or against fluid therapy during the dying phase. 2) There is inadequate precision of the term end of life care (ELC) and insufficient differentiation between modes of dehydration of palliative care patients. 3) Evaluation of dehydration based on its clinical appearance is considered the method of choice compared to invasive procedures. 4) Detailed clinical assessment of symptom reversibility in terminal dehydration by an appropriate fluid challenge is mandatory in the decision-making process. 5) If despite adequate rehydration measures, complete reversibility of the clinical picture of dehydration can no longer be achieved since organ systems are gradually deteriorating, the cessation of clinically assisted hydration (CAH) can be considered. 6) If symptoms of dehydration are reversible after fluid challenge and no other patient wishes to the contrary are known, fluid management should be continued in the context of symptom control. 7) Hyperhydration represents a considerable threat during fluid management that needs to be prevented by noninvasive monitoring procedures. In conclusion, if CAH is applied as a part of ELC the hydration status needs to be individually appraised and all therapeutic measures constantly need to be adapted to the findings of diligent monitoring procedures.
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The acute phase of complex regional pain syndrome (CRPS) is pathophysiologically characterized by an activation of the immune system and its associated inflammatory response. During the course of CRPS, central nervous symptoms like mechanical hyperalgesia, loss of sensation, and body perception disorders develop. ⋯ A stage adapted, targeted treatment could improve the prognosis. Effective multidisciplinary treatment includes the following: pharmacotherapy with steroids, bisphosphonates, or dimethylsulfoxide cream (acute phase), and antineuropathic analgesics (all phases); physiotherapy and behavioral therapy for pain-related anxiety and avoidance of movement; and interventional treatment like spinal cord or dorsal root ganglion stimulation if noninvasive options failed.
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Evaluation of the patient's medical history and a physical examination are the cornerstones of risk assessment prior to elective surgery, and may help to optimize the patient's preoperative medical condition and guide perioperative management. Whether performance of additional technical tests (e. g., blood chemistry, electrocardiography, spirometry, chest x‑ray) can contribute to reduction of the perioperative risk is often not well known or controversial. Similarly, there is considerable uncertainty among anesthesiologists, internists, and surgeons with respect to perioperative management of the patient's long-term medication. ⋯ The joint recommendations reflect the current state-of-the-art knowledge as well as expert opinions, because scientific-based evidence is not always available. These recommendations will be subject to regular re-evaluation and updating when new validated evidence becomes available. Contribution available free of charge by "Free Access".
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Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis". ⋯ The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.
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The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. ⋯ In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).