Der Anaesthesist
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Transport of critically ill patients from the ICU for diagnostic and therapeutic purposes (e.g. CT, endoscopy, radiological catheter-assisted interventions) is a challenge and has steadily increased over the years. ⋯ Proper education and experience in critical care medicine are additional characteristics of the transport team. When these prerequisites are fulfilled a "non-transportable" patient is just as unlikely as a "non-anesthetizable" patient.
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Several in vitro and animal studies have demonstrated the immunosuppressive effects of opioids and an increased risk of infection. The clinical relevance of these findings is unclear. In this review the relevant animal and human studies on the relationship of opioid use and risk of infection are summarized. ⋯ In the majority of animal studies an increased risk of infection was demonstrated but in human studies these findings were contradictory. However, these studies were frequently underpowered because they involved small patient collectives and do not reflect the standards of evidence-based medicine. In summary, a causal relationship between opioid therapy and an increased risk of infection could neither be conclusively demonstrated nor fully excluded.
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The main target of treatment in patients with head trauma is to maintain the physiological parameters within the following normal limits: intracranial pressure (ICP) below 20 mmHg, cerebral perfusion pressure (CPP) between 50 and 70 mmHg, normoxemia (SpO(2) >90%), normocapnia (paCO(2): 35-38 mmHg), normoglycemia (80-130 mg/dl) and normothermia (36.0-37.5 degrees C). Space-occupying intracranial bleeding or edemas must be evacuated immediately. ⋯ Mild hyperventilation, therapeutic hypothermia, or decompressive craniectomy should be used solely in patients with a persistent ICP increase. Infusion of calcium antagonists or glucocorticoids is never indicated in patients with head trauma.
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Patients undergoing coronary artery bypass grafting increasingly show severe co-morbidities, which can negatively affect the outcome. Recent developments in cardiac surgery have therefore focused on minimizing the invasiveness of the procedure by revascularization on the beating heart without cardiopulmonary bypass, and by reducing surgical trauma using smaller surgical incisions. Progress in minimally invasive cardiac surgery has led to minimally invasive anesthesia, i.e. using high thoracic epidural anesthesia as the sole technique in the conscious patient (awake coronary artery bypass grafting, ACAB). ⋯ A particular cause of concern during ACAB surgery is the development of spinal epidural hematoma the risk of which has been estimated to be as high as 1:1,000. A thorough risk-benefit analysis has therefore to be made. Currently, ACAB surgery remains limited to few specialized centers and highly selected patients.
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The success of an operation does not only depend on a perfect surgical technique, an appropriate anesthesia, convenient surgical instruments and functional technical equipment, but also on a proper operative positioning. Meeting the requirements of the surgeon, the positioning has also to be in accordance with the patient's individual needs. ⋯ The surgeon is in charge for the positioning, but the performance is done in a horizontal division of work between surgeon and anesthesiologist. This article describes standard positions, demonstrates their realization and special damages, and points out juristic aspects as well as technical items like operating table and positioning facilities.