Der Anaesthesist
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Succinylcholine and mivacurium are degraded more slowly in patients with a qualitatively or quantitatively reduced plasma cholinesterase and are therefore known for inducing a prolonged postoperative apnea. Perioperative laboratory screening even including plasma cholinesterase activity testing will not prevent this due to a possible aberration only in the qualitative cholinesterase activity. This is illustrated by introducing two cases reports of prolonged apnea after administration of mivacurium or succinylcholine. ⋯ Only extensive laboratory chemical tests are sufficient to prevent this possible complication. Due to the rare incidence there is no evidence for recommending these laboratory investigations in all patients. Once prolonged apnea occurs following the administration of mivacurium or succinylcholine the best choice is ongoing ventilation combined with a sufficient sedation.
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Case Reports
[Color duplex sonographic findings in an iatrogenic arteriovenous fistula of the vertebral artery].
The report describes a rare case of an iatrogenic arteriovenous fistula of the vertebral artery to the vertebral vein which arose after insertion of a central venous catheter via the jugular vein. We give special attention to the role of colour duplex sonography in the primary diagnosis of such fistulas. As can be seen from published reports with this non-invasive examination, the diagnosis of fistulas could not be established in all cases, where an abnormal communication between the vessels was later revealed by angiography. ⋯ Consequently only fistulas in the visible parts of the artery can be detected by sonography. In our case the most important criteria of duplex sonography for an arteriovenous fistula were fulfilled and the diagnosis was confirmed by angiography. This procedure with primary use of colour duplex sonography and additional clarification of uncertain findings by angiography, seems to be reasonable if the symptoms are compatible with the diagnosis of an arteriovenous fistula of the neck vessels.
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Tracheostomy is one of the oldest procedures in surgery. Although it was traditionally used for treatment of upper airway stenosis, the primary surgical indication is now in the long-term intensive care unit patient. Here, the aims are avoidance of damage to the larynx, earlier weaning from artificial respiration and improved nursing care. ⋯ Current meta-analyses of prospectively randomised studies show a lower complication rate than with conventional methods. Furthermore, serious sequelae such as tracheal stenosis are rare in the long-term course. However, conventional operative tracheostomy still has its place, particularly in circumstances where the new methods are contraindicated.
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Since its introduction into the operating room, transesophageal echocardiography (TEE) has proven to be an invaluable diagnostic tool for perioperative patient management. TEE allows direct visualization of structural and functional cardiac abnormalities. Therefore, it has become the most important imaging technique to evaluate valular function. ⋯ The severity of regurgitant blood flow across an incompetent valve can be assessed using color flow, continuous or pulsed-wave Doppler. Surgical patients experience significant changes in blood pressure, intrathoracic pressures and volume status in the perioperative period. Therefore, the interaction between these parameters and valvular function is the focus of recent clinical studies and might in future contribute to the perioperative as well as anesthesiological management of patients with valvular dysfunction.
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To evaluate the role of intraoperative real-time transesophageal echocardiography (TEE) for the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension. ⋯ Intraoperative TEE is a useful adjunct to the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension.