Anesthesia and analgesia
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The management of massively transfused trauma patients has improved with a better understanding of trauma-induced coagulopathy, the limitations of crystalloid infusion, and the implementation of massive transfusion protocols (MTPs), which encompass transfusion management and other patient care needs to mitigate the "lethal triad" of acidosis, hypothermia, and coagulopathy. MTPs are currently changing in the United States and worldwide because of recent data showing that earlier and more aggressive transfusion intervention and resuscitation with blood components that approximate whole blood significantly decrease mortality. ⋯ The ideal amounts of plasma, platelet, cryoprecipitate and other coagulation factors given in MTPs in relationship to the red blood cell transfusion volume are not known precisely, but until prospective, randomized, clinical trials are performed and more clinical data are obtained, current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1. Future prospective clinical trials will allow continued improvement in MTPs and thus in the overall management of patients with trauma.
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Anesthesia and analgesia · Jun 2009
ReviewPeripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability.
Postoperative ileus (POI), a transient cessation of coordinated bowel function after surgery, is an important health care problem. The etiology of POI is multifactorial and related to both the surgical and anesthetic pathways chosen. Opioids used to manage surgical pain can exacerbate POI, delaying gastrointestinal (GI) recovery. ⋯ This new class is investigational for POI management with the goal of accelerating the recovery of upper and lower GI tract function after bowel resection. In this review, we summarize the mechanisms by which POI occurs and the role of opioids and opioid receptors in the enteric nervous system, discuss the mechanism of action of PAM-OR antagonists, and review clinical pharmacology and Phase II/III POI trial results of methylnaltrexone and alvimopan. Finally, the role of anesthesiologists in managing POI in the context of a multimodal approach is discussed.
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Anesthesia and analgesia · Jun 2009
ReviewNew therapeutic agents for diabetes mellitus: implications for anesthetic management.
Multiple hormones and transmitter systems contribute to glucose homeostasis and the control of metabolism. Recently, the gastrointestinal peptide hormones glucagon-like peptide 1 and amylin have been shown to significantly contribute to this complex physiology. These advances provide the foundation for new treatments for diabetes mellitus. ⋯ Rimonabant, the selective endocannabinoid receptor antagonist, had been used in European countries for the treatment of obesity; it has recently been withdrawn for this indication. This drug exhibited therapeutic benefits for metabolic variables and for type 2 diabetes mellitus. Anesthesia providers caring for patients with diabetes mellitus will need to understand the implications of these new therapies in perioperative settings, particularly with respect to side effects and interactions.
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Anesthesia and analgesia · Jun 2009
Improvement in the quality of randomized controlled trials among general anesthesiology journals 2000 to 2006: a 6-year follow-up.
We previously assessed all randomized controlled trials (RCTs) from four anesthesiology journals from January 2000 to December 2000. We identified key areas for improvement in the study protocol design and implementation and in data analyses. This study was repeated for the year 2006 to determine if improvements have occurred during the 6-yr interval. ⋯ There appears to have been a general improvement in the overall quality of RCT reporting among the major anesthesiology journals from the year 2000 to 2006. However, many articles could be improved with respect to randomization blinding, observer blinding to continuing study results (i.e., no unplanned interim data analysis), and a full discussion of Type II error in negative trials. Responsibility to improve the quality of the anesthesiology literature rests with investigators to design, implement and report high quality RCTs, and with peer reviewers and journal editors to set the standard for manuscript reporting. Periodic reassessments of the literature can serve to improve and maintain the quality of clinical trials reporting.
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Anesthesia and analgesia · Jun 2009
Randomized Controlled TrialThe efficacy of intrathecal morphine with or without clonidine for postoperative analgesia after radical prostatectomy.
In this randomized study, we compared intrathecal (i.t.) morphine with or without clonidine and i.v. postoperative patient-controlled analgesia (PCA) morphine for analgesia after radical retropubic prostatectomy. ⋯ IT morphine provided a significant reduction in morphine requirement during the first 48 postoperative hours after a radical prostatectomy. The addition of clonidine to i.t. morphine reduced intraoperative sufentanil use, prolonged time until first request for PCA rescue, and further prolonged analgesia at rest and with coughing.