Der Anaesthesist
-
The perioperative morbidity and mortality is mainly influenced by the type and duration of surgery as well as the patient's preoperative state of health. Anesthesia per se, however, may also result in severe perioperative (patho) physiological changes, which may be both desired (e.g. analgesia, vasodilation in vascular surgery) or detrimental (e.g. hypothermia, ventilatory depression) and which may differ depending on the anesthetic technique used (e.g. general anesthesia vs. regional anesthesia). Yet, all anaesthetic techniques have in common, that their effects are not limited to the duration of the surgical intervention, but may expand far into the postoperative period. ⋯ The fact that clear advantages for a single technique have not yet been demonstrated must not, however, result in anesthetic 'nihilism'. Rather there may be good reasons in the individual patient (e.g. lack of a recovery room), to prefer a certain anesthetic technique or drug over another, in order to lower the individual risk of anesthesia. Whether the use of a certain technique-e.g. spinal or epidural anesthesia-may contribute to a reduction of specific postoperative surgical complications (e.g. rate of reocclusion subsequent to peripheral vascular surgery) is presently under investigation.
-
The extent of myocardial damage occurring during acute myocardial infarction is time dependent, and there is abundant evidence from most clinical trials that mortality reduction is greatest in patients treated early with thrombolytic agents, although beneficial effects have been shown with treatment initiated up to 12 h after onset of symptoms. All studies on prehospital thrombolysis have conclusively shown the practicability and safety of patient selection and administration of the thrombolytic agent. The accuracy of diagnosis in the prehospital setting was comparable to trials of in-hospital thrombolysis, e.g., in the Myocardial Infarction Triage and Intervention Project (MITI) 98% of the patients enrolled had subsequent evidence of acute myocardial infarction. ⋯ The results of randomized studies comparing the results of prehospital and in-hospital thrombolysis seem to justify the prehospital institution of thrombolytic therapy, especially in rural areas where transport times to the hospital are long and the expected time gain is largest. The choice of the thrombolytic agent seems to be of minor importance and should follow prehospital practicability (bolus injection) and costs. Aspirin should be given to all prehospital patients with suspected myocardial infarction regardless of thrombolytic therapy.
-
Randomized Controlled Trial Clinical Trial
[The effect of needle type and immobilization on postspinal headache].
Post-dural puncture headache (PDPH) is a significant complication of spinal anaesthesia. Diameter and tip of the needle as well as the patient's age have been proven to be important determinants. The question of whether post-operative recumbency can reduce the risk of PDPH has not been answered uniformly. And besides, some studies referring to this subject reveal methodical failures, for example, as to clear definition and exact documentation of post-operative immobilization. Furthermore, fine-gauge needles (26G or more) have not been investigated yet. The first aim of our study was therefore to examine the role of recumbency in the prevention of PDPH under controlled conditions using thin needles. Secondly, we wanted to confirm the reported prophylactic effect of needles with a modified, atraumatic tip (Whitacre and Atraucan) by comparing them to Quincke needles of identical diameter. Most of the former investigators compared Quincke with atraumatic needles of different size regardless of the known influence of the diameter on PDPH. ⋯ The significantly higher incidence of PDPH after spinal anaesthesia with 26-gauge Quincke needles compared to the 27-gauge Quincke and the 26-gauge Atraucan group confirmed the importance of both needle diameter and design of its tip. The Atraucan cannula has not been examined in a controlled study (in comparison with Quincke needle of the same diameter) before. In accordance with other investigators we found patient's age and number of puncture attempts as additional predictors of PDPH. Consequent bed rest, however, was not able to reduce its incidence. Our studies reveal the poor compliance of patients with regard to mobilization/immobilization, a problem which possibly has not been considered enough in former studies examining the influence of bed rest on PDPH. Based on the literature and the present findings, we recommend using thin needles with atraumatic tips for spinal anaesthesia if possible. Recumbency presents an avoidable stress for patients as well as medical staff and should no longer be ordered.
-
The shift of age distribution within the population of industrialized societies has led to an increased need of treating diseases in elderly patients and at the same time bearing an increased operative risk. Today, the development of surgical techniques and intensive care treatment enables us to carry out numerous procedures in geriatric patients. Innovative surgical techniques like minimal invasive surgery with minor trauma due to the surgical approach changed patient's categories, also. ⋯ Contrasting experiences made in most other countries and especially in the third world, in Germany economic restrictions have not been encountered as of yet. Economical conditions, an increase in surgical procedures in elderly patients and advances in medical science will continue to change the surgical patient's characteristics profoundly. From the physicians viewpoint we have actively participate in this development by personal interaction with the patient, by interdisciplinary cooperation and prompt social and political action.