Current clinical pharmacology
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Curr Clin Pharmacol · Jan 2015
ReviewAnesthetic pharmacology and perioperative considerations for the end stage liver disease patient.
The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. ⋯ An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.
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Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. ⋯ With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.
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Curr Clin Pharmacol · Jan 2015
ReviewAnesthetic pharmacology and perioperative considerations for heart transplantation.
From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with endstage heart disease.
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Curr Clin Pharmacol · Jan 2015
ReviewLung transplantation: perioperative pharmacology and anesthetic considerations.
In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U. ⋯ From appropriate patient selection, to optimal organ selection, surgical procedure, and immediate and long-term postoperative care, the medical process involves multiple healthcare providers and requires a very well-organized and committed healthcare system to achieve optimal surgical results. Understanding the pharmacology involved in the care of the lung transplant patient is of utmost importance to achieve appropriate organ preservation, immunosuppression, hemodynamic stability, and adequate anesthetic depth, while avoiding drug toxicity and side effects. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the medications most commonly administered to this patient population, throughout the perioperative period.
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Kidney transplants are routinely performed at medical centers around the world. Concurrent with improved surgical techniques, a better understanding of the pharmacology involved in the perioperative anesthetic management has led to improved outcomes in these patients. This chapter reviews the perioperative pharmacologic considerations surrounding kidney transplant patients from the viewpoint of the transplant anesthesiologist.