Der Anaesthesist
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Neuraxial anesthesia is an established and safe procedure in perioperative pain therapy which can help to minimize complications and to improve perioperative outcome. In patients with acquired bleeding disorders by comorbidities or concomitant antithrombotic medication an individual decision should be made based on risks and benefits. A large number of literature references and guidelines help making a decision, for example the recently updated evidence-based guidelines of the American Society of Regional Anesthesia and Pain Medicine for patients receiving antithrombotic or thrombolytic therapy. ⋯ Evidence-based recommendations for neuraxial anaesthesia in patients with hemophilia, vWD or ITP cannot be offered. Each patient has to be treated individually with appropriate caution. This overview is intended to assist in the decision for or against neuraxial anesthesia in these patients, with emphasis on the pathophysiological background, blood investigations and case reports from the literature.
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Airway management is a core task for anesthesiologists. Deficiencies in training or equipment as well as fateful complications in this field are responsible for a significant proportion of anesthesia-associated morbidity and mortality. ⋯ Nevertheless, the "cannot intubate cannot ventilate scenario" still occurs and regularly results in poor outcome, such as permanent neurological deficits or even death. Therefore, awake fiberoptic intubation remains the gold standard in the expected difficult airway because when applied correctly this technique never leads to a point where a patient's respiration is compromised as a result of medical measures before a secure airway has been established.
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The case presented describes the combined onset of heparin-induced thrombocytopenia II (HIT) and post-transfusion purpura (PTP) 5-10 days following exposure to heparin and blood transfusion during aortic dissection repair. On day 4 the platelet count decreased by 40% and D-dimers started to increase again. Despite a low clinical probability for HIT-II at this time (4T score of 3) serological testing was done the next day and yielded a negative test result. ⋯ Careful evaluation of the time-related magnitude in platelet decrease, patient history, course of D-dimers, screening ultrasonography and ROTEM® seem to be helpful to initiate early appropriate therapy before serological test results become available. In contrast to the Clauss method of fibrinogen measurement, assessment of clot firmness in ROTEM® is not influenced by argatroban. Moreover, ROTEM® reveals the compensatory effects of increased functional fibrinogen on clot firmness during severe thrombocytopenia as an important variable for anticoagulation therapy during thrombocytopenia with increased thromboembolic risk.