Der Anaesthesist
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Thoracic epidural anaesthesia (TEA) faces growing interest as an adjuvant anaesthetic and postoperative analgesic regimen. The procedure allows a specific blockade of nociceptive reflex arches and may exert beneficial effects on stress-induced alterations of organ function. Myocardial blood flow to areas at risk is improved, and paradoxical reactions of atherosclerotic coronary arteries after sympathetic stimulation are suppressed. ⋯ Although lumbar epidural anaesthesia is preferred by many anaesthesiologists as there is no risk of traumatizing the spinal cord, many positive effects are forgone. With insufficient rostral spread of a lumbar epidural block above the fifth thoracic level, cardiac complications can occur due to reflex activation of sympathetic outflow in unblocked thoracic regions. When the contraindications are carefully observed, TEA can be safely performed in most patients.
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Randomized Controlled Trial Clinical Trial
[Preoperative hemodilution with bovine hemoglobin. Acute hemodynamic effects in liver surgery patients ].
Haemoglobin solutions can be an alternative to allogeneic red-cell transfusions because they combine colloid osmotic with oxygen transport properties. Since severe toxic side effects have been overcome by ultrapurification, clinical interest has been focused on haemodynamics changes during application of haemoglobin preparations. The present clinical study examines changes of haemodynamic and oxygen transport parameters during and after haemodilution with ultrapurified polymerized bovine haemoglobin (HBOC-201) in comparison to hydroxyethyl starch (HES). ⋯ Patients did not show any severe complications during and after infusion of HBOC-201. However, vasoconstrictive side effects resulted in increased systemic but not pulmonary resistance. Ongoing studies with higher doses of HBOC-201 applied in a larger number of patients will probably reveal potential clinical consequences of the demonstrated haemodynamic changes.
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Many patients still suffer from unnecessary pain in the postoperative period. Waiting for new technologies or drugs will not improve the status of acute pain management. The establishment of an acute service is needed to reduce the incidence of postoperative pain. Acute pain therapy is one of the great challenges we have to take up.
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Nociception is a protective system of the body which prevents it from injury and tissue damage. Human beings respond to noxious stimuli by moving away. They learn by pain to avoid these situations in future. ⋯ Good antinociception may be even more important than it is assumed today. Anand demonstrated a lower morbidity and mortality in 45 newborns undergoing cardiothoracic surgery, when general anaesthesia was performed with high-dose sufentanil versus halothane supplementary doses of morphine. Anaesthesiologists have to reconsider the quality of general anaesthesia: the antinociception of their regimen.
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Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. ⋯ Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.