Der Anaesthesist
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Addicts have an exaggerated organic and psychological comorbidity and in cases of major operations or polytrauma they are classified as high-risk patients. Additional perioperative problems are a higher analgetics requirement, craving, physical and/or psychological withdrawal symptoms, hyperalgesia and tolerance. However, the clinical expression depends on the substance abused. ⋯ Equally important perioperative treatment principles are stabilization of physical dependence by substitution with methadone (for heroin addicts) or benzodiazepines/clonidine (for alcohol, sedatives and hypnotics addiction), avoidance of stress and craving, thorough intraoperative and postoperative stress relief by using regional techniques or systematically higher than normal dosages of anesthetics and opioids, strict avoidance of inadequate dosage of analgetics, postoperative optimization of regional or systemic analgesia by non-opioids and coanalgetics and consideration of the complex physical and psychological characteristics and comorbidities. Even in cases of abstinence (clean) an inadequate dosage must be avoided as this, and not an adequate pain therapy sometimes even with strong opioids, can potentially activate addiction. A protracted abstinence syndrome after withdrawal of opioids can lead to increased response to administered opioids (e.g. analgesia, side-effects).
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Drotrecogin alfa (activated) (DrotAA) represents a therapeutic advance in the treatment of severe sepsis. In the pivotal PROWESS trial DrotAA had demonstrated a significant decrease in 28-day mortality, most evident in the subgroup of patients at higher risk of death. Thus, DrotAA was licensed throughout Europe for treatment of adult patients with severe sepsis with multiple organ failure when added to best standard care. ⋯ The ENHANCE open-label trial enrolled similar patients to the PROWESS trial and the observed 28-day mortality was consistent with the results seen in the PROWESS trial. Survival rates for patients receiving DrotAA early within 24 h from the first sepsis-induced organ dysfunction were significantly higher than in patients treated later. In this overview we will discuss the results of the ENHANCE and ADDRESS trials in the context of the PROWESS study and clinical implications for the treatment with DrotAA.
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Drotrecogin alpha (recombinant human activated protein C, rhAPC; Xigris) is an immune modulating treatment principle that has been shown to significantly reduce mortality in patients with severe sepsis. Currently, the identification of patients in intensive care that may benefit from such a treatment is insufficient. The importance of this evidence-based treatment modality is commonly ignored for reasons of increased cost. ⋯ This may benefit patients with severe sepsis of not longer than 48 h duration, an APACHE II score of > or =25 or > or =2 failing organs and no exclusion criteria. Extending the indication beyond this group should be discussed as a last resort in patients with a fulminant clinical course, such as in meningitis, and based on data from retrospective subgroup analyses. Patients with severe sepsis following community-acquired pneumonia with progressive organ dysfunction may also benefit from activated protein C treatment in addition to an otherwise best standard of care.
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The endovascular treatment of diseases of intracranial and spinal vessels has become widely accepted in recent years. The patient is usually treated under general anesthesia and in choosing an appropriate anesthesia regimen and an optimized pre-interventional preparation, the anesthesiologist can influence the postinterventional result. The working environment in the angiography suite should address the requirements of a routine procedure and the necessities of complication management. ⋯ After the procedure the patient has to be monitored for at least 24 h. Peri-interventional and postinterventional complications, such as thrombo-embolism or hemorrhage, must be managed aggressively and consequently by the anesthesist to improve the postinterventional outcome. Therefore a close collaboration between the anesthesiologist and the neuroradiologist is essential.
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Randomized Controlled Trial Comparative Study
[Pharmacodynamics of two different propofol formulations].
Propofol is nowadays available in various lipid formulations. We compared two different propofol formulations with respect to pharmacodynamics, using the EEG and clinical signs. ⋯ The investigated lipid formulations have no influence on the pharmacodynamics of propofol.