Der Anaesthesist
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Diagnostic and interventional procedures in children often need to be performed under sedation. This prevents pain and stress in children and provides optimal examination conditions. ⋯ Organization, schedule, medication, equipment, monitoring and post-anesthesiology care should be institutionally defined. A professional anesthesiology management of pediatric patients is an important factor to increase the quality of care, patient safety and patient satisfaction.
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Randomized Controlled Trial
Spontaneously breathing anesthetized patients with a laryngeal mask airway: positive end-expiratory pressure does not improve oxygen saturation.
Spontaneous ventilation is a popular mode of ventilation for patients with the laryngeal mask airway (LMA). Studies have shown, however, that spontaneous ventilation impairs gas exchange and that assisting or controlling ventilation results in higher oxygen saturation. Atelectasis during general anesthesia is a well described mechanism which impacts on gas exchange. ⋯ The application of a PEEP of +7 cm H₂O with a LMA under spontaneous ventilation cannot be recommended. Limitations of our study were the selection of healthy patients and omitting pre-oxygenation before induction which might have limited the development of atelectasis. In addition arterial partial pressure of oxygen (p(a)O₂) measurements could have revealed subtle changes in oxygenation.
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During surgical procedures of the upper respiratory tract anesthesiologists and surgeons are in a kind of competition situation because of the close spatial relationship between the airway of the patient and the surgical area. Especially in laryngeal surgery the use of high-frequency jet ventilation (HFJV) offers an alternative to the endotracheal tube. During HFJV the ventilation gas is intermittently administered by an injector with a high frequency into the airway which is open to the outside. ⋯ Severe tracheal stenosis, risk of excessive bleeding during the procedure, patients at risk for aspiration and exacerbation of lung diseases are depicted as contraindications for HFJV. Complications under HFJV are rare despite the limited conditions for monitoring gas exchange and mechanics of ventilation in contrast to conventional ventilation. A particular challenge for the anesthesiologist is the use of HFJV during laryngeal laser surgery.
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Opioids are the most potent drugs for treatment of acute and chronic pain. However, accumulating evidence suggests that opioids may paradoxically also enhance pain, often referred to as opioid-induced hyperalgesia. Opioid-induced hyperalgesia is defined as an increased sensitivity to pain or a decreased pain threshold in response to opioid therapy. ⋯ However, it remains unclear whether opioid-induced hyperalgesia develops during continuous chronic application of opioids or on their withdrawal. This review provides a comprehensive summary of clinical research concerning opioid-induced hyperalgesia and the molecular mechanisms of opioid withdrawal and opioid tolerance and other potential mechanisms which might induce hyperalgesia during opioid therapy will be discussed. The status quo of our knowledge will be summarized and the clinical relevance of opioid-induced hyperalgesia will be discussed.
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Evaluation of the patient's medical history and a physical examination are the cornerstones of risk assessment prior to elective surgery and may help to optimize the patient's preoperative medical condition and to guide perioperative management. Whether the performance of additional technical tests (e.g. blood chemistry, ECG, spirometry, chest-x-ray) can contribute to a reduction of perioperative risk is often not very well known or controversial. Similarly, there is considerable uncertainty among anesthesiologists, internists and surgeons with respect to the perioperative management of the patient's long-term medication. ⋯ These recommendations aim to ensure that surgical patients undergo a rational preoperative assessment and at the same time to avoid unnecessary, costly and potentially dangerous testing. The joint recommendations reflect the current state-of-the-art knowledge as well as expert opinions because scientific-based evidence is not always available. These recommendations will be subject to regular re-evaluation and updating when new validated evidence becomes available.