Der Anaesthesist
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The religious organization of Jehovah's Witnesses numbers more than 7 million members worldwide, including 165,000 members in Germany. Although Jehovah's Witnesses strictly refuse the transfusion of allogeneic red blood cells, platelets and plasma, Jehovah's Witness patients may nevertheless benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The present review describes the perioperative management of surgical Jehovah's Witness patients aiming to prevent fatal anemia and coagulopathy. The cornerstones of this concept are 1) education of the patient about blood conservation techniques generally accepted by Jehovah's Witnesses, 2) preoperative optimization of the cardiopulmonary status and correction of preoperative anemia and coagulopathy, 3) perioperative collection of autologous blood, 4) minimization of perioperative blood loss and 5) utilization of the organism's natural anemia tolerance and its acute accentuation in the case of life-threatening anemia.
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The perioperative management of patients belonging to the faith of Jehovah's Witnesses poses two equally difficult problems for physicians due their strict refusal of allogeneic blood transfusions: From a medical point of view everything must be done to avoid fatal anemia and coagulopathy. On the other hand, the physician is confronted with the legal problem even in extreme cases, whether the wishes of the patient, i.e. the religiously motivated right to self-determination, should or even must be followed when despite all preventative measures as described in this case, the risk of fatality is only avoidable by a blood transfusion and therefore represents the only life-saving option. In order to be able to answer this question this article supplies information on the unanimously recognized conditions in the jurisdiction and prevailing legal opinion and derives the consequences for the physician that this does not necessarily signify an unconditional legal obligation in association with a patient directive.
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Because of the high vulnerability of the brain as a primary target, neuroanaesthesia requires a close look at basic physiological principles and factors of influence during surgery and subsequent intensive care. Anticipatory management is crucial for anaesthesia within the scope of neurosurgical interventions: essential components of anaesthesia management must already be prepared before the surgical procedure. Intracranial compliance and pressure determine the patient's fate; accordingly they have to be assessed correctly and measured continuously. ⋯ For the treatment of intracranial hypertension, osmotherapy is still of the highest value. Decompressive craniotomy seems to have become a promising alternative, although this must be judged to date as a last resort therapy. Perioperative care of patients with complex intracranial pathologies thus needs a close interaction and cooperation between the operation theatre and intensive care units in the sense of continuous track anaesthesia.
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Tooth damage during anaesthesia could be reduced by using tooth protectors during endotracheal intubation. The effectiveness of different models was investigated using an upper jaw model. ⋯ Preformed dental shields are useful for reducing the force applied to the teeth and potentially reducing the probability of tooth damage during laryngoscopy. However, the shield with the highest force reduction capability is relatively large and expensive which makes general use almost impossible. The model Beauty pink was slightly less force reducing and could be considered as an inexpensive and yet effective tool for clinical assignment.