Der Anaesthesist
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In this review article the special anesthesiological problems of opioid tolerance and surgical interventions will be presented. These affect patients with a long-term opioid therapy of chronic pain, addicts with long-term substitution therapy and addicts with current or previous heroin addiction ("clean"). For all patient groups a guarantee of continuous and adequate analgesia (avoidance of fear and increasing patient compliance), exploiting suitable regional anesthesia or regional analgesia procedures when possible, and prevention of a physical opioid withdrawal syndrome have utmost priority. ⋯ Opioid therapy with inclusion of a non-opioid is necessary following major operations or for severe postoperative pain, even as i.v. patient-controlled analgesia (i.v. PCA) if needed. For these patients a relapse to addiction can be provoked by insufficient administration of analgesics, not by pain management including opioids.
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Review Meta Analysis
[Perioperative beta-receptor blockade. For and against].
Results from recent studies have questioned the application of beta-receptor blockers for reduction of morbidity and mortality during the perioperative period. This holds true especially for patients with no or only low cardiac risk. Although beta-receptor blockade was a form of standard therapy at the end of the 1990s, data today show no clear evidence for such a therapy not even in patients at risk for cardiac events. At least in patients with low risk the initiation of beta-receptor blockade during the perioperative period might lead to side-effects, thereby increasing morbidity and mortality.
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General anesthesia and mechanical ventilation affect gas exchange, ventilation and pulmonary perfusion and there is an increasing body of evidence that mechanical ventilation itself promotes lung injury. Lung protective mechanical ventilation in patients suffering from acute lung injury or acute respiratory distress syndrome by means of reduced tidal volumes and limited plateau pressures has been shown to result in reduction of systemic inflammatory mediators, increased ventilator-free days and reduction in mortality. ⋯ There is a lack of clinical evidence that lung protective ventilation strategies as used in patients with lung injury may improve clinical outcome of patients with uninjured lungs. The question of which ventilatory strategy will best protect normal human lungs remains unanswered.