Der Anaesthesist
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Pain relief should be considered part of a multimodal postoperative approach. Combining patient-controlled pain therapy with other measures i.e. respiratory therapy or early mobilisation improves the outcome after surgery. In many patients adequate postoperative pain relief can be achieved by an optimal use of traditional pain management strategies. ⋯ Dosage of patient-controlled intravenous opioids or epidural drug combinations must be adjusted to the individual needs of the patients. Best results can only be achieved if the patient remains under observation by the pain service. This requires daily or twice daily rounds including an adequate documentation of pain relief, side effects and complications.
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The shift of age distribution within the population of industrialized societies has led to an increased need of treating diseases in elderly patients and at the same time bearing an increased operative risk. Today, the development of surgical techniques and intensive care treatment enables us to carry out numerous procedures in geriatric patients. Innovative surgical techniques like minimal invasive surgery with minor trauma due to the surgical approach changed patient's categories, also. ⋯ Contrasting experiences made in most other countries and especially in the third world, in Germany economic restrictions have not been encountered as of yet. Economical conditions, an increase in surgical procedures in elderly patients and advances in medical science will continue to change the surgical patient's characteristics profoundly. From the physicians viewpoint we have actively participate in this development by personal interaction with the patient, by interdisciplinary cooperation and prompt social and political action.
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Due to the recent development in operative medicine medical and organizational demands on perioperative patient care have changed significantly. Corresponding to the responsibility of the operative colleagues for therapy of the primary disease, anesthesiologists have to account for monitoring and treatment of vital functions throughout the perioperative period, starting from preoperative evaluation until postoperative care. The postanesthesia recovery unit has a key role in perioperative management. ⋯ The terminology should be changed in the future in order to better characterize the new task spectrum, e.g. in perioperative anaesthetic care unit (PACU) for medical and medicolegal reasons patient security must have absolute priority above economic aspects. Effective postoperative pain control using epidural or patient-controlled intravenous analgesia may increase patient comfort and reduce postoperative complications caused by sympathoadrenergic activation. Both method can be safely used on normal wards provided that close cooperation and training of ward personnel is guaranteed as well as continuous supervision by a specialized acute pain service.
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Review
[Clinical studies on the peripheral effect of opioids following knee surgery. A literature review].
In this article 34 randomized controlled trials examining peripherally mediated opioid effects after knee surgery are discussed. All studies examined small doses of morphine injected intraarticularly at the end of knee surgery, but not all studies did show an analgesic effect of the peripheral opioid. Because of differing study designs a meta-analysis of the data is not possible. ⋯ But at least during the first two hours the effect is small or else doubtfull. Therefore a combination with bupivacain, a local anesthetic which acts rapidly but only for some hours can be recommended. Most authors testing this combination found it most useful.