Anesthesia and analgesia
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Acute kidney injury (AKI) remains a common complication in the perioperative setting affecting patients' short- and long-term outcome. Because therapeutic options are restricted to the use of renal replacement therapy, preventive strategies have become increasingly important. Several substances have been investigated for preventing AKI with limited to no effects. ⋯ The most promising preventive strategy to date seems to implement a bundle of supportive measures in patients at high risk for AKI as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) group. This strategy includes the avoidance of nephrotoxic drugs and contrast agents, avoidance of hyperglycemia, optimization of perfusion pressure and hemodynamics with consideration of a functional hemodynamic monitoring, and close monitoring of renal function in patients at high risk for AKI. This review discusses new renal biomarkers for identifying kidney damage, the background of why the different measures of the KDIGO bundle might positively affect renal function and prevent the development of AKI, and presents the current literature of biomarker-based approaches in AKI.
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Anesthesia and analgesia · Dec 2020
Derivation, Validation, Sustained Performance, and Clinical Impact of an Electronic Medical Record-Based Perioperative Delirium Risk Stratification Tool.
Postoperative delirium is an important problem for surgical inpatients and was the target of a multidisciplinary quality improvement project at our institution. We developed and tested a semiautomated delirium risk stratification instrument, Age, WORLD backwards, Orientation, iLlness severity, Surgery-specific risk (AWOL-S), in 3 independent cohorts from our tertiary care hospital and describe its performance characteristics and impact on clinical care. ⋯ The AWOL-S delirium risk stratification tool has moderate accuracy for delirium prediction in a cohort of elective surgical patients, and performance is largely unchanged in emergent/preadmitted surgical patients. Using AWOL-S risk stratification as a part of a multidisciplinary delirium reduction intervention was associated with significantly lower rates of perioperative anticholinergic but not benzodiazepine, medications in those at high risk for delirium. AWOL-S offers a feasible starting point for electronic medical record-based postoperative delirium risk stratification and may serve as a useful paradigm for other institutions.
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Perioperative cardioprotection aims to minimize the consequences of myocardial ischemia-reperfusion injury. In isolated tissue and animal experiments, several treatments have been identified providing cardioprotection. ⋯ This review provides an overview of the currently available evidence regarding clinical implications of perioperative cardioprotective therapies from an anesthesiological perspective, highlighting nonpharmacological as well as pharmacological strategies. We discuss reasons why translation of promising experimental results into clinical practice and outcome improvement is hampered by potential confounders and suggest future perspectives to overcome these limitations.
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Anesthesia and analgesia · Dec 2020
ReviewTargeting Endothelial Dysfunction in Acute Critical Illness to Reduce Organ Failure.
During hyperinflammatory conditions that can occur in acute critical illness, such as shock or hypoperfusion, inflammatory mediators activate the endothelium, fueling a proinflammatory host-response as well as procoagulant processes. These changes result in shedding of the glycocalyx, endothelial hyperpermeability, edema formation, and lead to disturbed microcirculatory perfusion and organ failure. Different fluid strategies that are used in shock may have differential effects on endothelial integrity. ⋯ In addition, this review focuses on the effects of different fluid strategies on endothelial permeability. Also, potential mechanisms for treatment options to reduce endothelial hyperpermeability with ensuing organ failure are evaluated. Future research is needed to elucidate these pathways and to translate these data to the first human safety and feasibility trials.
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In the past, it was common practice to use a high tidal volume (VT) during intraoperative ventilation, because this reduced the need for high oxygen fractions to compensate for the ventilation-perfusion mismatches due to atelectasis in a time when it was uncommon to use positive end-expiratory pressure (PEEP) in the operating room. Convincing and increasing evidence for harm induced by ventilation with a high VT has emerged over recent decades, also in the operating room, and by now intraoperative ventilation with a low VT is a well-adopted approach. There is less certainty about the level of PEEP during intraoperative ventilation. ⋯ In addition, gas absorption-induced atelectasis and its association with adverse outcomes like postoperative pulmonary complications actually makes use of a high FIO2 less attractive. Based on the available evidence, we recommend the use of a low VT of 6-8 mL/kg predicted body weight in all surgery patients, and to restrict use of a high PEEP and high FIO2 during intraoperative ventilation to cases in which hypoxemia develops. Here, we prefer to first increase FIO2 before using high PEEP.