Medikamenten-Pocket Pädiatrie - Notfall- und Intensivmedizin (German Edition)

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Monat 6. Monat 7. Monat 8. Monat 9. Monat Lehre Vorlesung Praktikum Tipps Famulatur. KollegInnen Veranstaltungen. Mitarbeiter Dr. Prompt urological referral may be required. If necessary, insert a large-calibre catheter Shaldon catheter for this purpose. Low molecular weight LMW heparins, also called fractionated heparins, are without doubt the gold standard for perioperative thrombosis prophylaxis [ 35 ]. Remember, however, that there is at least a relative contraindication to the administration of LMW heparins in patients with impaired renal function use with caution when the creatinine concentration is 1.

This becomes less important in patients with end-stage renal failure requiring dialysis so that LMW heparins are again commonly prescribed in this situation. Table 18 Tab. Should a patient on dialysis need an ENT operation, the following should be taken into consideration:. If this is not possible, an extra dialysis session may be needed the day before surgery. The decisive lab test is the serum potassium concentration. As a general rule, do not give any potassium-containing solutions; perioperative fluid consists of scant 0.

Patients on dialysis have usually adapted to low haemoglobin concentrations, and this should be taken into account when determining the indication for red blood cell transfusion. If acute renal failure develops in the course of treatment, or there is further deterioration of previously impaired kidney function, check whether there is an indication for renal replacement therapy haemofiltration, haemodialysis.

Pädiatrische Notfälle im Rettungsdienst - 2. Altersgruppen und Gewicht

As consultation with the nephrologists is routinely required, categorical explanations can be dispensed with here. The serum creatinine concentration must be known before any X-ray contrast medium is given. POCT appliances with a creatinine option are extremely useful in this respect see above.

Magnetic resonance imaging MRI contrast medium can also cause renal damage. When the patient has impaired renal function, the first question to ask is whether CT without contrast medium would be sufficient in the circumstances or whether MRI unenhanced or with a macrocyclic contrast medium would be appropriate. If the indication for the use of contrast medium still exists, take the following measures:. Patients who are to undergo ENT surgery are often already being treated with anticoagulants [ 55 ], [ 56 ], [ 57 ]. The following risk factors are typical:.

In each case, the risk of perioperative bleeding has to be weighed up against the risk of a thromboembolic event. Do not use coumarin derivatives perioperatively when there is more than a low risk of bleeding. The same applies to all operations under general anaesthetic, as even a gentle intubation technique may cause haematomas to form at the base of the tongue, in the supraglottic region or the glottis. Consider continuing this type of anticoagulant therapy only for surgical interventions with a low risk of bleeding and no danger of compromising the airways, such as the removal of skin lesions.

Otherwise switch the oral anticoagulant to heparin perioperatively. LMW heparin bridging therapy is widely used, with self-management by the patient.

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Nevertheless, remember that none of the available products is licensed for this purpose — even if the manufacturer sometimes provides brochures on the subject. Bridging must consist of therapeutic doses e. It is only possible to monitor therapy by determining anti-Xa activity target value: 0. Consequently, adverse events are not uncommon Figure 5 Fig.

Heparin administration should be interrupted about four hours before surgery and re-started hours afterwards without any bolus injection. The patient is then re-warfarinised with overlapping administration. Unfractionated heparin also has the advantage that it can be almost completely antagonised at any time by administering protamine as the antidote. It should be diluted and administered slowly through a peripheral venous access.

Remember the risk of heparin-induced thrombocyto penia every time heparin is administered. Monitor the platelet count regularly. Request further diagnostic investigations HIT II rapid test if there is a significant fall in the platelet count. Heparin-induced thrombocytopenia type I HIT I may occur at any time from the first day onwards and is a non-immune heparin-platelet interaction. As a rule, heparin therapy can be continued without reservation. Heparin-induced thrombocytopenia type II HIT II is due to antibody formation; it occurs 5—20 days after the first administration of heparin, and just a few hours after re-exposure.

Thromboembolic vascular occlusion is common. Vitamin K antagonises the effects of coumarin derivatives, although the onset of action is usually delayed.

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Intravenous administration is reserved for severe or life-threatening haemorrhage. PPSB is therefore much more efficient than fresh frozen plasma. Do not forget, however, that PPSB is of human origin and, under the transfusion law, its administration has to be fully explained to the patient and documented. Each ml of fresh frozen plasma FFP contains one unit of the plasma clotting factors and their inhibitors. This calculation emphasises the small benefit of fresh frozen plasma to improve coagulation in situations other than hypovolaemia.

As a meta-analysis showed an increased risk of coronary and cerebrovascular events when aspirin had been discontinued perioperatively, Vogel Kahlmann et al. Nevertheless, assume a higher risk for surgical procedures on the larynx and trachea, as well as for extensive tumour resections.

Elective surgical interventions should therefore be postponed; perform operations that cannot wait with continuation of the dual medication. After the insertion of a coronary stent, dual platelet aggregation inhibitors are continued for at least four weeks with bare metal stents and for at least 6—12 months with drug-eluting stents [ 59 ]. In contrast to aspirin, nonsteroidal anti-inflammatory drugs NSAIDs inhibit platelet aggregation reversibly, i. So it is sufficient to stop this medication 1—2 days before the planned operation.

The therapeutic spectrum of anticoagulant therapy has recently been extended by the introduction of products designated as new oral anticoagulants NOAC s. The indications for these new substances are still evolving; at the present time, all three products are approved for prophylaxis of DVTs after lower limb joint replacement, dabigatran and rivaroxaban also have marketing authorisation for stroke prophylaxis in atrial fibrillation.

None of them can be administered by feeding tube. The dose may have to be adjusted in cases of renal insufficiency; details are given in the relevant SPCs. Routine lab tests are not required or possible to monitor any of these three medications. The standard PT Quick and aPTT tests do not react to the presence of the active substances, so that problems arise in patients with acute bleeding e. While it was previously possible to determine an overdose of oral anticoagulant easily with the PT Quick , a diagnostic tool is lacking for NOACs.

In addition, the effects of NOACs cannot be reversed at the present time although antidotes are being developed. The situation is made even more difficult when patients cannot say which medication they are taking. The following statements apply:. There is currently a diagnostic gap in the event of acute haemorrhage and unknown medication, as the presence of NOACs cannot be determined with absolute certainty by standard tests and each substance requires specific tests. Symptomatic therapy is therefore the most important.

PPSB can be given in cases of severe and life-threatening haemorrhage. Otherwise it is sufficient to discontinue the therapy. Start treatment again as soon as possible. Perioperative bridging with LMW heparins is not recommended at the present time nor is it an approved indication. Clotting factor concentrates are available for the treatment of haemophilia:. Postoperative coagulation management in the individual case should be discussed with a specialist in transfusion medicine. If products of human origin are used, they have to be documented correctly in accordance with the transfusion law.

The three different types of vWD differ in their severity and treatment Table 20 Tab. The following tests aid in diagnosis:. Type II vWD can be subdivided by means of a special diagnostic test.

Vorgehaltene Medikamente auf notarztbesetzten Rettungsmitteln in Deutschland

A dose of 0. One adverse effect of desmopressin is water retention. Take this into account in the perioperative fluid regimen fluid balance chart. Pseudothrombocytopenia may be mistakenly diagnosed due to the presence of EDTA in the sample, so that a check on citrated blood is recommended before introducing any further measures. True thrombocytopenia has many possible causes. If thrombocytopenia is first discovered in the context of an elective surgical intervention, the patient should be referred to a haematologist for a full workup.

Depending on the cause of the thrombocytopenia, the preoperative administration of corticosteroids e. Heparin-induced thrombocytopenia may occur after the administration of heparin see section 6. Thrombocytopenia in severe infections may indicate the complication of progressive consumption coagulopathy disseminated intravascular coagulation DIC. With more pronounced thrombocytopenia, consider the option of platelet transfusion. Platelet concentrate should not be given until immediately before the operation because of its short half-life.

If there is any question of allogeneic stem cell transplantation, make every effort to ensure that the platelet transfusion is HLA-compatible. Whole blood is subjected to thrombelastometry, a development of thrombelastography [ 60 ]. FIBTEM measurements deactivate the platelets, so that the results correspond solely to fibrin-induced clotting.

The method has proved its worth especially in major surgical procedures on patients with impaired liver function and septic conditions. Without doubt, every clinical and surgical facility must have access to a POCT system for blood gas analysis. These systems are used mainly for intraoperative diagnostic investigation, but also provide a good service for patients whose general condition deteriorates acutely and for preoperative risk assessment. Besides the routine tests for pH, p O 2, p CO 2 and HCO 3— , most systems can also measure the haemoglobin concentration and blood glucose levels.

Although venous blood provides information useful for orientation purposes, arterial blood gas analysis is more reliable. If no catheter is in situ for arterial blood pressure measurement and it is not possible to insert one, blood samples can be obtained by radial artery puncture.

Publikationen: Universitätsklinikum Frankfurt am Main

Capillary blood gas analysis e. The p O 2 in particular is not valid with capillary sampling. Treatment is needed in the acute case with non-compensated disorders, identified by an abnormal pH normal range: 7. First ascertain whether the disorder is of a primary respiratory or metabolic origin. If there is respiratory acidosis, the p CO 2 is raised CO 2 narcosis ; if the condition is of metabolic origin, the HCO 3 concentration is lowered. Primary respiratory disorders may require mechanical ventilation to blow off carbon dioxide.

The first question to ask with a primary metabolic condition is that of its origin. Look into the possibility of medication with metformin if there is a concomitant increase in the serum lactate levels see section 9. A similar combination of lab results can be seen with mesenteric infarction. Treatment depends on the assumed or confirmed cause. The first distinction to be made is between hyperhydration and dehydration, which can be determined from the haematocrit. Secondly, distinguish between isotonic, hypertonic and hypotonic states, which can be done on the basis of the serum osmolarity [ 9 ].

Considerations are always based on the intravascular state, details of which can be seen in Table 21 Tab. As long as the arterial blood pressure is being monitored, volume deficiency can easily be identified by an undulating curve pulse pressure variation with slow conduction 6.

Moreover, the fluid balance can be estimated on the basis of the central venous pressure CVP , as long as a central venous catheter lies in the superior vena cava; although it is possible to measure the CVP with a line in the inferior vena cava, it is of limited value. Do not overestimate the value of a single CVP measurement [ 18 ], [ 39 ], [ 41 ].

Hyponatraemia [ 61 ] may have the following causes:. Because sodium is located predominantly in the extracellular space, a low serum sodium is not necessarily an expression of sodium deficiency but much rather of hypotonic hyperhydration. In this situation, giving sodium would be wrong; on the contrary, the hyperhydration has to be dealt with by administering diuretics. If there is an indication for sodium, it must be given slowly, as too-rapid adjustment carries a risk of osmotic demyelinating diseases central pontine myelinolysis, extrapontine myelinolysis [ 62 ].

Isotonic NaCl solution is preferred to adjust the electrolyte balance as long as there is an associated hypochloridaemia; use hypertonic solutions with caution. These substances inhibit sodium resorption and potassium secretion, which may lead to hyponatraemia and hyperkalaemia. Serum chloride [ 9 ] concentration is often less closely observed in routine clinical practice than the levels of the cations.

Deviations from the norm are relatively frequent. Hypochloridaemia, usually in association with hyponatraemia, is sometimes seen in cachectic cancer patients who have an inadequate food and fluid intake. It may lead to confusional states. Take the same precautions as described for sodium above. On the other hand, draining gastric juices via a nasogastric tube or a PEG tube can lead to isolated hypochloridaemia.

The same may occur with chronic hypercapnia and on treatment with mineralocorticoids. In the case of hyperchloridaemia, therefore, prefer to use an electrolyte solution with a more physiological chloride content e. Routinely used infusion solutions have therapeutically relevant differences in composition of which you should be aware. As a rule, most attention is paid to the potassium [ 9 ] concentration.

Hypokalaemia can affect cardiac function just as much as hyperkalaemia. As taking loop diuretics is often a part of the treatment of arterial hypertension, hypokalaemia occurs frequently in everyday practice. Interpretation of the potassium concentration requires knowledge of the pH and glucose levels, as these three parameters interact. An increase in the blood pH by 0.

Hyperglycaemia causes a fall in potassium levels. Insulin drives potassium into the cells. Implausible or unexpected lab test results always have to be looked at critically, and may indicate preanalytical error tourniquet applied for too long, haemolysis because of a narrow cannula, sample taken from infusion arm or distal CVP access, etc. Overdose is practically impossible when kidney function is intact. One banana contains about 14 mmol potassium per g. The usual 1 millimolar KCl solution 7.

KCl solution must be diluted before administration: max. Potassium replacement in hypokalaemia with typical ECG changes needs monitoring on intensive care. When assessing the serum calcium [ 9 ] levels, check whether the total calcium or the ionised calcium commonly measured by many POCT systems has been determined. The normal ranges differ:. There is obviously room for error in assessment if the method used and the normal range are unknown. As a general rule, hypocalcaemia in asymptomatic patients e. In the event that it is necessary to treat hypocalcaemia, oral replacement is preferable, whenever possible.

Calcium levels in the body are strictly regulated by a hormone feedback loop parathormone, calcitonin , so hypercalcaemia is always pathological unless it is due to preanalytical error and needs to be investigated for cause. The following therapeutic options are open for symptomatic treatment of hypercalcaemia:. Without doubt, diabetes mellitus is one of the most commonly encountered pre-existing diseases in routine clinical practice.

Stop metformin-containing medicines at least 48 hours before elective surgery, because of the risk of lactic acidosis see section 9. Do not give any oral antidiabetic agents or intermediate- or long-acting insulins on the day of operation, but control the blood glucose by giving rapid-acting insulin — with repeated doses if necessary — on the basis of the blood glucose levels.

In acute conditions such as pneumonia and sepsis, a correlation between glucose levels and outcome has been described, so it is always important to keep the blood glucose within the normal range as much as possible. Preoperative lab tests can be dispensed with if there is no evidence of thyroid disease. TSH measurement is sufficient before elective surgery if the patient is known to have thyroid disease.

When the TSH concentration is in the normal range, there is no contraindication to surgical intervention. Elevated TSH levels indicating hypothyroidism and reduced TSH levels indicating hyperthyroidism or thyroid autonomy require preoperative workup and appropriate treatment. Postpone elective surgery until the patient is euthyroid. In the case of urgent surgical intervention, initiate hormone replacement for hypothyroidism and thyrostatic therapy for hyperthyroidism. Hypothyroidism is to be expected after radiotherapy in the region of the thyroid gland. Administration of iodine-containing contrast medium for computed tomography means that subsequent thyroid gland scintigraphy cannot be evaluated.

If there is any suspicion of a thyroid carcinoma, the use of contrast medium during a CT scan should be challenged. Patients requiring ENT surgery are not infrequently on long-term steroid therapy. Typical indications are:. As exogenous therapy with corticosteroids impairs or may impair the endogenous function of the adrenal cortex, determine before surgery whether there is an indication for supplemental perioperative steroids to prevent postoperative adrenal cortical insufficiency. As a rule, 50 mg hydrocortisone is given as a short infusion, followed by a further 50 mg via perfusor over 12 hours.

Table 22 Tab. It is now a generally accepted standard that patients with healthy stomachs, who are prescribed monodrug therapy with corticosteroids i. Increasing life expectancy increases the prevalence of dementia syndromes. The ENT surgeon therefore often faces patients with dementia [ 65 ] in both the outpatient and inpatient settings e.

Patients admitted to hospital have particular problems with orientation in the unaccustomed environment. Surgical procedures associated with general anaesthesia as well as new medication can also lead to an acute deterioration in cognitive function. Causative treatment is not possible but contact with the usual carers often helps. Symptomatic treatment may require sedation e. Antidementia drugs do not work in the short-term, if at all. Make every effort to discharge patients promptly back to their usual surroundings. The differential diagnosis includes delirium see section 8. The cardinal symptoms are bradyhypokinesia, rigor, tremor and impaired postural reflexes.

Further symptoms include dementia, disturbances of smell, and disorders of the autonomic nervous system. The pathophysiology consists of a dopamine deficiency in the substantia nigra with the formation of intracellular inclusion bodies Lewy bodies. Amantadine is, in fact, a virostatic agent but also has antagonistic effects on the NMDA receptors. Its advantage lies in its rapid onset of action. Both these clinical pictures are the expression of thiamine vitamin B deficiency and are seen particularly with alcohol abuse [ 67 ].

In patients with a history of alcohol abuse and neuropsychiatric features, there is nothing to argue against a trial of thiamine. This term delirium [ 68 ], [ 69 ], [ 70 ] is derived from the Latin delirare : to deviate from the straight track, to be deranged. It describes CNS changes characterised by an acute onset and fluctuating disturbances of mental and psychomotor function, affect, and level of consciousness [ 71 ]. A distinction is made between delirium with pre-existing dementia and that without.

Delirium requires prolonged hospital stay and is associated with a higher mortality. The aetiology and pathogenesis of delirium are currently explained by a multifactorial model. Acute delirium has to be differentiated from chronic dementia; Table 23 Tab. Should restraints be absolutely necessary, keep the patient under constant supervision. SSRIs are indicated if there is any evidence of a depressive episode — however, the onset of action is not seen for several days.

Synonyms and antonyms of tonsillär in the German dictionary of synonyms

The following aspects need to be considered in the prevention of delirium tremens due to alcohol withdrawal :. The usual drinking can possibly even be tolerated for minor interventions e. As a rule, however, patients who have to come into hospital for a short stay — urgent diagnosis of cancer — will not be motivated to long-term abstinence.

Continued alcohol consumption is therefore a justifiable option, as long as the patients organise their own supplies. Intravenous ethanol administration is not an option. Monitor arterial blood pressure continuously as hypotension and bradycardia may be dose-limiting factors. Clonidine therapy has to be tapered off gradually.

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  6. Ventilation equipment has to be on hand because of the risk of respiratory depression, use is therefore preferred in patients with tracheostomies. Central anticholinergic syndrome may occur as a complication of a general anaesthetic. The central action may be excitatory agitation or depressant stupor, respiratory depression [ 51 ]. Peripheral effects include tachyarrhythmias, flushing of the skin and urinary retention. General anaesthetics, hypnotics, opioids and centrally acting parasympatholytics such as atropine may trigger CAS.

    ENT inpatients are also at risk of stroke [ 67 ], [ 72 ], particularly patients with cancer and a corresponding risk profile. Remember that anticoagulation with heparins lowers only the risk of venous thromboembolism and not the risk of cerebrovascular events emboli mainly affect the lungs; the exception is paradoxical embolus with a patent foramen ovale. This is particularly relevant when anticoagulant therapy for atrial fibrillation is discontinued perioperatively.

    As a rule of thumb, pulmonary emboli rarely occur in an adequately anticoagulated patient but the same does not apply to strokes. Emergency diagnostic investigation is indicated as soon as an acute neurological deficit is noticed except when a decision for palliative care has already been taken. Investigation consists, on the one hand, of determining the clinical neurological status and, on the other, of diagnostic imaging CT with perfusion measurement.

    CT allows bleeding to be ruled out at once and with certainty, but ischaemia cannot always be detected or excluded immediately. Further management is based on neurological measures. If lytic therapy is indicated, remember that there will be an increased risk of bleeding at the operation site. The indication for mechanical ventilation e. Emergency l igation of the internal carotid artery or common carotid artery cannot be avoided in some cases of acute tumour haemorrhage a temporary balloon occlusion test prior to elective surgery allows the risk of cerebral ischaemia to be estimated.

    If the internal carotid artery is acutely occluded, the following measures may reduce the chances of ischaemic infarction:. It is a good idea to perform a tracheostomy if the patient does not already have one, as it makes weaning easier and less stressful. Provided no neurological symptoms arise, the patient can start to be mobilised into a sitting position after about 7—10 days. Curative treatment may require hemicraniectomy Figure 7 Fig. Displacement of the respiratory tract by tumours, swelling or bleeding is a typical complication in ENT surgery; it may cause hypoxic brain injury in isolated cases.

    CNS tolerance of hypoxia depends on many influencing factors. The most important thing to do in the acute case is to cool the previously hypoxic patient for neuroprotection [ 72 ] , [ 73 ]. These biomarkers can also be measured in the CSF, although it is doubtful that the results are more significant. The cut-off for a poor prognosis determined in earlier studies varies considerably, however, so the reader is strongly recommended not to base therapeutic decisions on these results at the present time [ 74 ].

    For this reason, no cut-off value is given here. For the latest information see [ 75 ]. Myoclonus occurring after a hypoxic event Lance-Adams syndrome is also seen as an unfavourable prognostic sign. Effective symptomatic treatment consists of:. Patients who have been on intensive care for a long time may develop symptoms and signs of critical illness polyneuropathy [ 67 ], [ 72 ].

    The clinical picture covers multiple neurological symptoms — disorders of sensation, motor function critical illness myopathy CIM and the autonomic nervous system. Predisposing factors include sepsis, multiorgan failure, and long-term ventilation. Characteristically, there is difficulty in weaning the patient from the ventilator, without there being any pulmonary reason, and limb weakness due to atrophic paralysis denervation atrophy and even assumed tetraparesis.

    The diagnosis is based on electrophysiological findings electromyography EMG , nerve conduction velocity NCV ; the condition is one of axonal neuropathy. CIP obviously delays mobilisation and rehabilitation. There is some evidence that aggressive management of blood glucose levels especially the prevention of hyperglycaemia can reduce the incidence of CIP. Signs of CIP may resolve completely but there may also be residual defects. Although CIP and CIM are regarded as separate conditions, they occur in the same circumstances and have considerable overlap.

    Patients who are under legal guardianship at the time of hospital admission or surgery are not usually a problem. Obviously both guardian and patient have to be fully informed. This means that a personal briefing session has to be held with the guardian in the same way as for a patient who is legally competent. On this basis, information solely by fax is viewed as inadequate, as this obviously confirms that there was no personal contact between doctor and patient or guardian.

    The situation is different when the need for guardianship does not arise until during the hospital stay. Typical situations are prolonged postoperative ventilation and postoperative delirious states. The responsible guardianship court must be contacted promptly in such circumstances. In principle, the guardianship court responsible is the one with jurisdiction over the place where the patient is at the present time. It is helpful to designate a guardian by name, as long as that person has agreed to act in this capacity. If there is no suitable guardian close to the patient, the court will appoint a professional guardian.

    If the patient has already signed an advance directive in the form of an enduring power of attorney for health care not to be confused with a living will , then guardianship is not necessarily required. The National Association of Notaries maintains a central register where enduring powers of attorney for health care can be lodged. Only the guardianship courts have access to this information, so the responsible court should be contacted if there is any uncertainty whether such an enduring power of attorney for health care exists.

    Restraint [ 76 ] has to be considered if a patient is at risk of self-harm or a danger to other people, when other means such as talking to them or sedation are not sufficient. Rule out any possible treatable causes for psychomotor excitability promptly. There are clear rules for using restraints, intended to prevent future legal problems.

    An acute danger to others e. The same applies to behaviour with an acute risk of self-harm e. If conditions are foreseeable and likely to be prolonged rule of thumb: next working day the restraints should be approved by the responsible guardianship court. The court is also a good source of information on any open questions. The reason and duration of restraint has to be documented preferably in both the medical and nursing records, with photos. Restrained patients require uninterrupted observation. Staff should be trained in the use of the commonly employed patient restraints e.

    Forced administration of medication e. That said, such cases are the exception in the ENT department. This clearly does not apply when there is an obvious error e. Medication errors may sometimes occur when one generic is exchanged for another discount agreements or more than one doctor is involved in prescribing: another problem lies in the deplorable habit, when a drug is available in various strengths, of not prescribing the right strength but rather allowing the patient to break higher-strength tablets to give the desired dose.

    It has been reported repeatedly that medicines supposed to be taken once a week have been mistakenly ingested every day e. Pill organisers or dosettes can also pose problems, especially when they are filled by lay persons and the medicines can no longer be identified clearly. A pill identification guide like the German Gelbe Liste Identa , in book form or as a smartphone app, may be useful. Figure 8 Fig. On the other hand, blister packs put together by a pharmacist Figure 9 Fig.

    When entering the medication into a treatment chart, take particular care with look alike, sound alike LASA drugs [ 77 ]:. HAES vs. A detailed list of reported near-miss mistaken identities can be found in reference [ 78 ]. Hospital pharmacies stock a cross-section of the most commonly used drugs. It is therefore not always possible to provide exactly the same medication as the patient usually takes from the hospital formulary, but it is not necessary to do so on a regular basis.

    Conversion tables exist for many drug classes e. Switching products inevitably opens up new sources of error but, for economic reasons, they often cannot be eliminated completely. If in doubt, discuss the matter with the hospital pharmacist. Another source of error arises when inpatients continue to be responsible for taking their own medication. In this case, control over the accuracy and reliability of administration is lost. Some control should be established e. On the day of operation, all medication and not just the premed should be prepared and administered under supervision.

    This recommendation results from the fact that most patients are given a sedative the evening before elective surgery, and this may affect their alertness the following morning. The cardioprotective effect of perioperative beta-blocker medication for primary prevention is disputed, but the benefits of beta-blockers in overt heart failure have been demonstrated.

    If beta-blocker therapy has to be introduced preoperatively, it should be given for at least one month before the planned operation. Any exceptions must be communicated clearly before the operation, to prevent the postoperative administration of inappropriate analgesics. If it becomes necessary to give medicine previously administered by mouth via a feeding tube nasogastric tube, PEG tube , first check whether this is possible.

    Not only is the physical solubility of the drug relevant, but also the fact whether the active substance is intended for direct gastric administration at all. For example, gastro-resistant, modified release, and sublingual products cannot usually be crushed. Reference [ 79 ] gives further recommendations. In addition, the tube manufacturers usually provide very helpful brochures on administering drugs via feeding tubes.

    It is easy to understand why no written instructions are possible in emergency situations. To a large extent, this practice prevents hearing and comprehension errors. Any drugs administered during the emergency management have to be documented straight afterwards. It helps if empty ampoules are not thrown away immediately but kept, for example, in a kidney dish.