Der Anaesthesist
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Clinical Trial
[Perioperative use of medical hypnosis. Therapy options for anaesthetists and surgeons].
Surgical treatment of patients under local anaesthesia is quite commonly restricted by limited compliance from the patient. An alternative to treatment under pharmacological sedation or general anaesthesia could be the application of medical hypnosis. With this method, both suggestive and autosuggestive procedures are used for anxiolysis, relaxation, sedation and analgesia of the patient. ⋯ Medical hypnosis is not considered to be a substitute for conscious sedation or general anaesthesia but a therapeutic option equally interesting for anaesthesists and surgeons.
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Molecular biology has revolutionized medicine by increasing our understanding of the pathophysiological mechanisms of disease and the ability to assess genetic risk. Individual differences in disease manifestation and course in intensive care medicine often cannot be explained by known phenotypic risk factors alone. ⋯ TNF-alpha, Il-10), infectious diseases such as pneumonia or meningitis, sepsis, ARDS, as well as the mortality of critically injured patients (polytrauma, severe brain trauma). Continued identification of such allotypes and haplotypes may not only provide insight as to why the response to treatment varies amongst individuals in the intensive care unit, but also may potentially decrease morbidity and mortality through improved risk assessment and the administration of prophylactic therapy.
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The process of evidence-based medicine incorporates structured clinical problem solving aimed at providing an optimal, patient-centred therapeutic approach. Evidence-based medicine is supported by justified therapeutic principles rather than physicians' intuition only. Few of the published articles allow firm conclusions for a rational patient approach. ⋯ Besides the careful analysis of source data, evidence-based medicine warrants the final evaluation of outcomes for process improvement. This can be obtained utilising surrogate parameters, such as organ failure, resource allocation, or quality of life, or crude mortality of the patients. The integration of personal know-how together with sufficient knowledge and critical appraisal of the current literature may finally lead to improved outcomes.
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Non-opioid analgesics play a central role in the management of postoperative pain. In this review, the pharmacology, the analgesic efficacy and the side-effects of non-opioid analgesics are summarized. First, the pharmacology of diclofenac, acetyl salicylic acid, dipyrone, acetaminophen and the COX-2 inhibitors is described. ⋯ Third, the major side-effects of non-opioid analgesics are discussed in relation to the pathophysiology, the frequency and the clinical relevance of these effects. In particular, side-effects on the gastrointestinal tract (ulcus formation), on coagulation (bleeding and thrombosis), on the renal (renal insufficiency), the pulmonary (bronchospasm) and the hematopoetic systems (agranulocytosis) are described. Recommendations for the clinical use of non-opioid analgesics for perioperative pain therapy are given.
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The pharmacokinetics of opioids are impaired in patients with liver and renal failure. Fentanyl, sufentanil, and alfentanil are metabolized in the liver. The extrahepatic metabolism by renal enzymes is gaining more importance in patients with severe liver disease. ⋯ The clearance of morphine is reduced in liver failure. In renal failure an accumulation of morphine metabolites has been demonstrated, and thus, application of morphine is not recommended in patients with liver and renal failure. A reduction in piritramide dosing is necessary in patients with liver failure.