Der Anaesthesist
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Bacteraemia and septicaemia are generally thought to be relative or absolute contraindications for central neural axis (CNA) blocks. Postulated mechanisms for haematogenous infection of the central nervous system (CNS) caused by subarachnoid or epidural puncture might be an accidental vessel puncture, a change of pressure in the subarachnoid space, and the induction of a "locus minoris resistentiae." Infectious complications of diagnostic lumbar puncture, spinal or epidural anaesthesia are very rare. Although in animals meningitis can be induced by subarachnoid puncture during bactaeremia, there is no study that proves an increased risk for bacteraemic patients. ⋯ Based on current knowledge, bacteraemia cannot be an absolute, but only a relative contraindication for CNA blocks. Antibiotic chemoprophylaxis should be given before the puncture and the patients must be closely followed after the anaesthesia, particularly for the development of spinal epidural abscess. Because of the possibly increased risk of infectious complications, informed consent should be obtained from the patient.
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Since the development of prognostic score systems in intensive care medicine in the 1980s score models have improved substantially and are now based on much larger databases. They have been validated in many multicenter and international studies all over the world. Prognostic scoring systems may be used for assessment of severity of illness, stratifying patients prior to randomization in clinical trials, evaluation and comparing outcome and survival (hospital mortality), quality assessment, cost-benefit analysis, and in clinical decision making. ⋯ Advances in computer technology should assist in achieving many of the future goals of prognostic scoring systems. Most of the physiological data are available from ICU monitors and computerized laboratory systems. By electronically interfacing with the ICU monitor an automated patient data entry is possible and will provide that prognostic scores can be made available to the clinician daily.
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Transoesophageal echocardiography (TEE) is recognised as a semi-invasive technique that has an increasing impact as a diagnostic tool in anaesthesia and intensive care medicine. However, adequate assessment of TEE is based on knowledge of basic echocardiographic principles and their limitations and sufficient educational training of the user. TEE has an established role in various clinical circumstances. ⋯ In patients with severe hypotension TEE may identify the cause, and thereby facilitate successful patient management. Moreover, TEE has an impact on the diagnosis of endocarditis and pathologic findings within the heart and pericardial sac. TEE-associated diagnosis and decision-making may lead to an improved clinical outcome, which in turn may lead to subsequent cost reduction.
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There is still a significant lack of treatment and rehabilitation facilities for chronic pain patients in Germany today. Most of all the treatment of low back pain and widespread pain syndromes or panalgesia is time consuming and complicated. The main problem of anaesthesiological pain clinics is the increase of these complex pain syndromes in the last years. ⋯ It is now clear that no one discipline or mode will suffice. Only a multidisciplinary and intensive approach will prevail, as discussed in this article. Unfortunately these multidisciplinary pain units are nearly not existing in Germany just as little as control of the effectiveness of pain treatment.
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Mivacurium is a short-acting, nondepolarising muscle relaxant of the benzylisoquinoline type that undergoes rapid breakdown by plasma cholinesterase. After 2.5 times the ED95 (0.2 mg/kg), tracheal intubation can be accomplished within 2-3 min following injection. ⋯ The principal side effects of mivacurium are facial flushing and a transient fall in blood pressure due to moderate histamine release following doses 3-4 times the ED95. In patients with end-stage liver or renal disease as well as those with atypical plasma cholinesterase, the duration of action of mivacurium is prolonged.