Anaesthesiology intensive therapy
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Anaesthesiol Intensive Ther · Jan 2016
Central venous pressure as an adjunct to flow-guided volume optimisation after induction of general anaesthesia.
Although the central venous pressure (CVP) is often used as a guide to volume status in major surgery and intensive care, fluid therapy should be guided by the response of the stroke volume (SV) to a fluid bolus. The present study evaluates whether the central venous pressure (CVP) can serve as an adjunct to decisions of whether or not fluid should be infused. ⋯ A low CVP suggests that the patient is lower on the Frank-Starling curve than indicated by SV as measured by FloTrac/Vigileo.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewMust hypervolaemia be avoided? A critique of the evidence.
Anaesthetists are cautioned to avoid hypervolaemia in their patients. The most cited reason is that hypervolaemia elicits the release of atrial natriuretic peptides that damage the endothelial glycocalyx layer. Although shedding of the glycocalyx causes extravasation of protein in inflammatory disorders, it is more uncertain whether hypervolaemia alone is enough to cause clinically important shedding. ⋯ A re-calculation based on theoretical ICG data, taking account of the transit time, shows the plasma volume expansion was closer to 100% than to 40% of the infused volume. This figure is supported by the dilution of the reported blood haemoglobin and plasma protein concentrations, as well as by other sources. In conclusion, only weak evidence supports a fluid-induced release of atrial peptides of sufficient size to alter the kinetics of colloid fluid by shedding of the endothelial glycocalyx layer.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewIntravenous balanced solutions: from physiology to clinical evidence.
"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered and supra-physiologic in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental effect on renal function associated with hyperchloremia. ⋯ After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solution on renal function in critically-ill patients (SPLIT trial, the 0.9% Saline vs Plasma-Lyte 148 for Intensive Cate Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions, secondly, by summarizing their potential pathophysiologic effects, and lastly, by presenting the clinical evidence available to support, at the moment, their use.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewCommon pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review.
Haemodynamic monitoring with transpulmonary thermodilution (TPTD) is less invasive than a pulmonary artery catheter, and is increasingly used in the Intensive Care Unit and the Operating Room. Optimal treatment of the critically ill patient demands adequate, precise and continuous monitoring of clinical parameters. Little is known about staff knowledge of the basic principles and practical implementation of TPTD measurements at the bedside. The aims of this review are to: 1) present the results of a survey on the knowledge of TPTD measurement among 252 nurses and doctors; and 2) to focus on specific situations and common pitfalls in order to improve patient management in daily practice. ⋯ TPTD has gained its place in the haemodynamic monitoring field, but, as with any technique, its virtue is only fully appreciated with correct use and interpretation.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewIntra-abdominal hypertension and abdominal compartment syndrome in burns, obesity, pregnancy, and general medicine.
Intra-abdominal hypertension (IAH) is an important contributor to early organ dysfunction in trauma and sepsis. However, relatively little is known about the impact of intra-abdominal pressure (IAP) in general internal medicine, pregnant patients, and those with obesity or burns. The aim of this paper is to review the pathophysiologic implications and treatment options for IAH in these specific situations. ⋯ Although non-operative measures come first, surgical decompression must not be delayed if these fail. Percutaneous drainage of ascites is a simple and potentially effective tool to reduce IAP if organ dysfunction develops, especially in burn patients. Escharotomy may also dramatically reduce IAP in the case of abdominal burns.