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INTRODUCTION AND OUTLINE OF THE THESIS

OUTLINE OF THE THESIS

Part 1

The first part of this thesis focuses on the question which procedures might be suitable for

sedation outside the OR, or whether these procedures should better be performed using

alternative techniques as general or local anaesthesia.

In

chapters 2 and 3,

we focus on the transfemoral implantation of the aortic valve

(TAVI). This procedure actually was started 2006 using general anaesthesia. Nowadays, an

increasing number of implantations is performed under sedation or – as in the AMC - using

only local analgesia.

1,2,3,4

Chapter 2

is a critical editorial discussing the question: does the form of anaesthesia,

which also means sedation, make the difference during TAVI procedures?

5

Looking at the

available evidence-based literature data, we cannot answer this question at this moment.

Nevertheless, there are forceful arguments to avoid general anaesthesia and deep sedation

during these procedures, preferring the fully awake patient only using local wound

infiltration with local analgesics, but with a cardiac anaesthesiologist as member of the

team.

Chapter 3

presents our own TAVI data:

6

between April 2010 and May 2013, 178 patients

underwent transfemoral TAVI under local anaesthesia combined with premedication or

light sedation. Interventional cardiologists performed all procedures in a multidisciplinary

team together with an anaesthesiologist in the cardiac catheterisation laboratory.

Chapter 4

attends to the different treatment options and the relevant form of anaesthesia

- or sedation - for a rare, disabling gastroenterological disease: achalasia.

7

Achalasia is

characterised by a reduced motility of the oesophagus coupled with the inability of the

lower oesophagus sphincter (LOS) to relax sufficiently. The outcome of this combination

is stasis of food, liquid, and saliva above the LOS.

8

Nowadays, there are different medical,

endoscopic, and surgical possibilities to treat achalasia. All of these treatment options set

as objective to reduce the spasm in the muscle layers of the LOS. Although the aim of the

different therapeutic interventions is the same, all alternatives require a special anaesthesia

approach.

Chapter 5

reviews the question: does each diagnostic or therapeutic procedure really need

sedation?

9

What is suitable if a procedure is only painful, but does not require a motionless

patient? Is it analgesia, sedation, both, or nothing at all? And how to handle the special

request for sedation demanded by the patient or operator?