Der Anaesthesist
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The process of evidence-based medicine incorporates structured clinical problem solving aimed at providing an optimal, patient-centred therapeutic approach. Evidence-based medicine is supported by justified therapeutic principles rather than physicians' intuition only. Few of the published articles allow firm conclusions for a rational patient approach. ⋯ Besides the careful analysis of source data, evidence-based medicine warrants the final evaluation of outcomes for process improvement. This can be obtained utilising surrogate parameters, such as organ failure, resource allocation, or quality of life, or crude mortality of the patients. The integration of personal know-how together with sufficient knowledge and critical appraisal of the current literature may finally lead to improved outcomes.
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Non-opioid analgesics play a central role in the management of postoperative pain. In this review, the pharmacology, the analgesic efficacy and the side-effects of non-opioid analgesics are summarized. First, the pharmacology of diclofenac, acetyl salicylic acid, dipyrone, acetaminophen and the COX-2 inhibitors is described. ⋯ Third, the major side-effects of non-opioid analgesics are discussed in relation to the pathophysiology, the frequency and the clinical relevance of these effects. In particular, side-effects on the gastrointestinal tract (ulcus formation), on coagulation (bleeding and thrombosis), on the renal (renal insufficiency), the pulmonary (bronchospasm) and the hematopoetic systems (agranulocytosis) are described. Recommendations for the clinical use of non-opioid analgesics for perioperative pain therapy are given.
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The pharmacokinetics of opioids are impaired in patients with liver and renal failure. Fentanyl, sufentanil, and alfentanil are metabolized in the liver. The extrahepatic metabolism by renal enzymes is gaining more importance in patients with severe liver disease. ⋯ The clearance of morphine is reduced in liver failure. In renal failure an accumulation of morphine metabolites has been demonstrated, and thus, application of morphine is not recommended in patients with liver and renal failure. A reduction in piritramide dosing is necessary in patients with liver failure.
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None of the currently available inhaled anesthetics has all of the properties of an "ideal" inhaled agent. The exceptionally low solubility of desflurane and sevoflurane offers a significantly greater precision of control over maintenance of anesthesia and a potential for a more rapid recovery from anesthesia than other inhaled anesthetics. Sevoflurane appears to offer some advantages regarding cardiovascular stability. ⋯ Renal toxicity is discussed for enflurane and sevoflurane. Breakdown products of volatile agents with carbon dioxide absorbents have to be mentioned especially for sevoflurane (compound A) and desflurane (CO). In contrast to intravenous anesthetics, volatile anesthetics are associated with cardio- and cerebroprotection.
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After various observational studies demonstrated a benefit of extracorporeal membrane oxygenation (ECMO) in the therapy of severe acute respiratory distress syndrome (ARDS), ECMO now represents an important contribution for ARDS therapy using clinical algorithms despite a lack of positive controlled studies. In specialized centers patients with severe ARDS and imminent hypoxia despite intensive conventional therapy, are treated with ECMO using blood pumps and artificial membrane lungs (oxygenators) for extracorporeal lung assist. ⋯ New oxygenators with significantly decreased blood resistance allow the clinical application of pumpless arteriovenous extracorporeal lung assist (ECLA). After these new developments indications for ECMO could be extended from use not only as ultimate ratio but to less severe ARDS to enable lung protective, less invasive mechanical ventilation.