Der Anaesthesist
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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.
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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.
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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.
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Due to the recent development in operative medicine medical and organizational demands on perioperative patient care have changed significantly. Corresponding to the responsibility of the operative colleagues for therapy of the primary disease, anesthesiologists have to account for monitoring and treatment of vital functions throughout the perioperative period, starting from preoperative evaluation until postoperative care. The postanesthesia recovery unit has a key role in perioperative management. ⋯ The terminology should be changed in the future in order to better characterize the new task spectrum, e.g. in perioperative anaesthetic care unit (PACU) for medical and medicolegal reasons patient security must have absolute priority above economic aspects. Effective postoperative pain control using epidural or patient-controlled intravenous analgesia may increase patient comfort and reduce postoperative complications caused by sympathoadrenergic activation. Both method can be safely used on normal wards provided that close cooperation and training of ward personnel is guaranteed as well as continuous supervision by a specialized acute pain service.