Der Anaesthesist
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Inhalation as well as total intravenous anesthesia have both advantages and disadvantages. The pros of an inhalation technique are mask induction without the initial need for intravenous access and precise dosing; the pros of an intravenous technique are postoperative quiet recovery and a low incidence of vomiting. With both techniques the aim is to reach a certain, most often constant effect site concentration, which after a short latent period equals the blood concentration. ⋯ Dosing of intravenous anesthetics is based on assumptions. For neonates and young infants an inhalation technique is often preferred because of metabolic immaturity and the resulting difficulties of dosing, whereas older children can often profit from a quiet awakening and a reduced incidence of vomiting. The increased availability of syringe pumps with incorporated algorithms as well as of electroencephalograph (EEG)-based monitoring systems will further promote the popularity of total intravenous anesthesia.
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Patient blood management (PBM) is a multidisciplinary approach focusing on the diagnosis and treatment of preoperative anaemia, the minimisation of blood loss, and the optimisation of the patient-specific anaemia reserve to improve clinical outcomes. Economic aspects of PBM have not yet been sufficiently analysed. ⋯ PBM combines various alternatives to the transfusion of red blood cells and improves clinical outcome. Costs of PBM vary from institution to institution and depend on the extent to which different aspects of PBM have been implemented. The quantification of costs associated with PBM is essential in order to assess the economic impact of PBM, and thereby, to efficiently re-allocate health care resources. Costs were determined at a single university hospital. Thus, further analyses of both the costs of transfusion and the costs of PBM-principles will be necessary to evaluate the cost-effectiveness of PBM.
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Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. ⋯ It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.
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Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. ⋯ Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.