Der Anaesthesist
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Remifentanil is a 4-anilidopiperidine mu-opioid analgesic which is rapidly metabolized by unspecific blood and tissue esterases. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia combines high-dosage opioid analgesia intraoperatively with a rapid and predictable postoperative awakening. ⋯ The present paper was designed to review the current knowledge on remifentanil and all aspects of its use in anaesthesiology. In addition, present data on the use of remifentanil for analgesia and sedation of the critically ill patient are summarized.
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Review Comparative Study
[Comparison of algorithms for management of the difficult airway].
Management of the difficult airway and maintenance of the oxygenation are the most important tasks of the anaesthetist. Respiratory problems are still the most important single cause for anaesthesia-related accidents with poor outcome. Algorithms are step-wise procedures developed from a great number of recommendations and are well suited to automation and training procedures. ⋯ This strongly depends on local circumstances and personal preferences. Daily practice is the condition for the successful use in an emergency situation. The management is easier if one uses a simple algorithm and as few instruments as possible.
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First observations that opioids may have disadvantageous effects on the immune response have been made more than 100 years ago. Today the immunosuppressive effect of morphine is well established. Drug-induced immunomodulation is of growing importance in modern anesthetic concepts. ⋯ A final statement regarding the clinical relevance of opioid-induced immunosuppression cannot be made at this point, since the existing clinical data are preliminary and inconclusive. Therefore, further clinical studies are mandatory to elucidate the influence of opioid treatment on immune regulation in different clinical settings in anesthesia, critical care, pain therapy and emergency medicine. Further investigations may help to not only provide sufficient analgesia by application of opioids, but also to assess advantages and disadvantages on immune function.
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The combination of proportional assist ventilation (PAV) and automatic tube compensation (ATC) is a promising concept for partial ventilatory support. In contrast to conventional pressure support ventilation (PSV), PAV+ATC provides dynamic pressure support depending on the patient's initial inspiratory effort. ⋯ Patients have the ability to modify the tidal volume in response to changes in ventilatory demand, thereby improving patient-ventilator interaction and breathing comfort when compared with PSV. However, since routine measurements of respiratory mechanics during augmented spontaneous breathing are currently unavailable but would be necessary for setting the support level as a function of respiratory system mechanics during PAV, this mode cannot yet be generally recommended for routine clinical use.
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Local anesthetics provoke reversible blockade of nerves by interaction with sodium channels in membranes of nerves. The uncharged molecular configuration of the local anesthetic penetrates the membrane from the outside and the charged configuration then interacts with the sodium channel from the inside. The potency of a local anesthetic is determined mainly by lipid solubility, the time of onset by the pK(a) of the substance and the duration of action by protein binding. ⋯ Local anesthetics show dose-dependent CNS and cardiac toxicity. Reports of toxicity, mainly involving bupivacaine and etidocaine initiated the development of ropivacaine which is the first aminoamide marketed as a pure S-enantiomer. Recently introduced was levo-bupivacaine, the S-enantiomer of bupivacaine.