Der Anaesthesist
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The perioperative morbidity and mortality is mainly influenced by the type and duration of surgery as well as the patient's preoperative state of health. Anesthesia per se, however, may also result in severe perioperative (patho) physiological changes, which may be both desired (e.g. analgesia, vasodilation in vascular surgery) or detrimental (e.g. hypothermia, ventilatory depression) and which may differ depending on the anesthetic technique used (e.g. general anesthesia vs. regional anesthesia). Yet, all anaesthetic techniques have in common, that their effects are not limited to the duration of the surgical intervention, but may expand far into the postoperative period. ⋯ The fact that clear advantages for a single technique have not yet been demonstrated must not, however, result in anesthetic 'nihilism'. Rather there may be good reasons in the individual patient (e.g. lack of a recovery room), to prefer a certain anesthetic technique or drug over another, in order to lower the individual risk of anesthesia. Whether the use of a certain technique-e.g. spinal or epidural anesthesia-may contribute to a reduction of specific postoperative surgical complications (e.g. rate of reocclusion subsequent to peripheral vascular surgery) is presently under investigation.
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Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. ⋯ With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU.
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Perioperative morbidity and mortality in noncardiac surgery are mainly due to cardiovascular complications. Therefore, perioperative risk assessment is crucial to avoid these adverse events. In patients above the age of 40 years, the ECG is a basic investigation, often providing hints for cardiovascular diseases. ⋯ The vascularization reduced the perioperative risk in particular in those patients with unstable angina or severe coronary artery disease. However, prophylactic revascularization the stable patient does not improve overall outcome, because the risk of the revascularizing procedure must be added to the risk of noncardiac surgery. Other diagnostic procedures like echocardiography, chest roentgenogram, routine scintigraphy, halter ECG or halter blood pressure measurement do not add information to the perioperative risk assessment, although these techniques might be very relevant in evaluating other coexisting diseases (heart failure; valve lesions, in particular aortic stenoses etc.) and can be useful to improve medical treatment preoperatively (e.g. normalization of blood pressure).