Anesthesia and analgesia
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Anesthesia and analgesia · Dec 2020
ReviewSystemic Inflammatory Response Syndrome After Surgery: Mechanisms and Protection.
The immune system is an evolutionary hallmark of higher organisms that defends the host against invading pathogens and exogenous infections. This defense includes the recruitment of immune cells to the site of infection and the initiation of an inflammatory response to contain and eliminate pathogens. However, an inflammatory response may also be triggered by noninfectious stimuli such as major surgery, and, in case of an overshooting, still not comprehensively understood reaction, lead to tissue destruction and organ dysfunction. ⋯ These options depend on uncovering the underlying mechanisms and could include pharmacologic agents, remote ischemic preconditioning protocols, cytokine blockade or clearance, and optimization of surgical procedures, anesthetic regimens, and perioperative inflammatory diagnostic assessment. Currently, a large gap between basic science and clinically confirmed data exists due to a limited evidence base of translational studies. We thus summarize important steps toward the understanding of the precise time- and space-regulated processes in systemic perioperative inflammation.
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Anesthesia and analgesia · Dec 2020
ReviewPerioperative Renoprotection: General Mechanisms and Treatment Approaches.
In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. ⋯ Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.
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Anesthesia and analgesia · Dec 2020
ReviewPerioperative Cardioprotection: General Mechanisms and Pharmacological Approaches.
Cardioprotection encompasses a variety of strategies protecting the heart against myocardial injury that occurs during and after inadequate blood supply to the heart during myocardial infarction. While restoring reperfusion is crucial for salvaging myocardium from further damage, paradoxically, it itself accounts for additional cell death-a phenomenon named ischemia/reperfusion injury. Therefore, therapeutic strategies are necessary to render the heart protected against myocardial infarction. ⋯ Fortunately, it can be mimicked pharmacologically, for example, by volatile anesthetics, noble gases, opioids, propofol, dexmedetomidine, and phosphodiesterase inhibitors. These substances are all routinely used in the clinical setting and seem promising candidates for successful translation of cardioprotection from experimental protocols to clinical trials. This review presents the fundamental mechanisms of conditioning strategies and provides an overview of the most recent and relevant findings on different concepts achieving cardioprotection in the experimental setting, specifically emphasizing pharmacological approaches in the perioperative context.
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Anesthesia and analgesia · Dec 2020
Opioid-Sparing Cardiac Anesthesia: Secondary Analysis of an Enhanced Recovery Program for Cardiac Surgery.
Cardiac anesthetics rely heavily on opioids, with the standard patient receiving between 70 and 105 morphine sulfate equivalents (MSE; 10-15 µg/kg of fentanyl). A central tenet of Enhanced Recovery Programs (ERP) is the use of multimodal analgesia. This study was performed to assess the association between nonopioid interventions employed as part of an ERP for cardiac surgery and intraoperative opioid administration. ⋯ Nonopioid interventions employed as part of an ERP for cardiac surgery were associated with a reduction of intraoperative opioid administration. Low and ultralow opioid use was not associated with significant differences in postoperative outcomes. These findings are hypothesis-generating, and future prospective studies are necessary to establish the role of opioid-sparing strategies in the setting of cardiac surgery.
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Anesthesia and analgesia · Dec 2020
Biography Historical ArticleAmbition for Self and for Specialty: Emery A. Rovenstine and the Politics of Organized Anesthesia, 1937-1947.
The letters between Emery Andrew Rovenstine, MD (1895-1960), and Arthur Ernest Guedel, MD (1883-1956), are a window into the personalities and politics of the creation of American anesthesiology. The ambition of these men, both personal and professional, lay at the heart of their sacrifices and successes. Their correspondence unmasked common struggles and foibles, humanizing these giants of our field. ⋯ Still, at various points in his career, Rovenstine was censured for self-promotion by leaders in anesthesiology and the general medical community. These moments brought to light issues of continued relevance today: inner tension between individual and group ambition, and professional friction between academic and political priorities in anesthesiology. In the end, it was an unapologetic blend of ambition for self and ambition for the specialty that allowed Emery Rovenstine to make his unique imprint on American anesthesiology.