Der Anaesthesist
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Because of the high vulnerability of the brain as a primary target, neuroanaesthesia requires a close look at basic physiological principles and factors of influence during surgery and subsequent intensive care. Anticipatory management is crucial for anaesthesia within the scope of neurosurgical interventions: essential components of anaesthesia management must already be prepared before the surgical procedure. Intracranial compliance and pressure determine the patient's fate; accordingly they have to be assessed correctly and measured continuously. ⋯ For the treatment of intracranial hypertension, osmotherapy is still of the highest value. Decompressive craniotomy seems to have become a promising alternative, although this must be judged to date as a last resort therapy. Perioperative care of patients with complex intracranial pathologies thus needs a close interaction and cooperation between the operation theatre and intensive care units in the sense of continuous track anaesthesia.
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In extreme situations, for example during emergencies or when facing surgery, patients exhibit heightened and focused attention and increased susceptibility to suggestion. In this trance-like state negative suggestion, usually spoken unintentionally can aggravate anxiety, stress and pain. On the other hand words can offer an opportunity to benefit the patient via positive suggestion. ⋯ Indications for such approaches are the preoperative visit, induction of anaesthesia, as well as operations under local or regional anaesthesia. An extreme example of the latter is awake craniotomy employing cranial nerve blocks and an awake-awake technique avoiding centrally acting drugs. Such hypnotic communication can help the patient to regain self-control and access to inner resources.
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While guidelines represent systematically developed aids for decision-making on appropriate courses of action, recommendations should focus the attention of the medical profession on noteworthy circumstances which are in need of amendment. The new recommendations on the "Execution of analgesia and anesthesia procedures in obstetrics" of the German Society for Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anesthetists (Berufsverband Deutscher Anästhesisten, BDA) in cooperation with the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) comprehensively fulfill these requirements. The new recommendations include not only revisions in the form of updating but also supplementations in the form of the new chapters "Initial care of newborns", "Postpartum hemorrhaging" and "Morbid obesity". In the following article relevant alterations to newly formulated or completely amended sections with consequences for the clinical practice will be discussed.
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In recent years delirium in the intensive care unit (ICU) has internationally become a matter of rising concern for intensive care physicians. Due to the design of highly sophisticated ventilators the practice of deep sedation is nowadays mostly obsolete. To assess a ventilated ICU patient for delirium easy to handle bedside tests have been developed which permit a psychiatric scoring. ⋯ A certain constellation of pre-existing patient-related conditions, the current diagnosis and surgical procedure and administered medication entail a higher risk for the occurrence of ICU delirium. A favored hypothesis is that an imbalance of the neurotransmitters acetylcholine and dopamine serotonin results in an unpredictable neurotransmission. Currently, the administration of neuroleptics, enforced physiotherapy, re-orientation measures and appropriate pain treatment are the basis of the therapeutic approach.
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The incidence of postoperative cognitive dysfunction (POCD) is often underestimated and not intuitively present by many anesthetists. POCD often occurs in the elderly but is also seen in younger patients. The incidence of POCD 1 week after non-cardiac surgery covers a span between 19-41% in patients older than 18 years. ⋯ The age of the patient is one of the main risk factors for the development of POCD. Data on how to avoid POCD are limited. However, the maintenance of homoeostasis is an important cornerstone of prophylaxis.