Cleveland Clinic journal of medicine
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In the last 7 years, 14 randomized controlled trials in patients with acute respiratory distress syndrome (ARDS) have shown that: Mechanical ventilation with a tidal volume of 6 mL/kg of predicted body weight is better than mechanical ventilation with a tidal volume of 12 mL/kg of predicted body weight. Prone positioning improves oxygenation but poses safety concerns. A high level of positive end-expiratory pressure does not improve survival. ⋯ Exogenous surfactant may improve oxygenation but has no significant effect on the death rate or length of use of mechanical ventilation. Low-dose inhaled nitric oxide has no substantial impact on the duration of ventilatory support or on the death rate. Partial liquid ventilation may be beneficial in young patients with acute lung injury or ARDS, although further study is needed to confirm this.
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The quality of postoperative pain management can be improved. Although many safe and effective therapies exist, their utilization varies considerably between and within institutions. Major challenges include the appropriate prescribing of analgesic therapies and the timely response to suboptimal pain control. Patients' satisfaction with their analgesic care may depend less on how well their pain is controlled and more on the attentiveness of their caregivers.
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Most patients with chronic kidney disease eventually become anemic. We should view the management of anemia in these patients as part of the overall management of the many clinically relevant manifestations of chronic kidney disease. Erythropoiesis-stimulating agents (ESAs) are safe and should be used, as treating anemia may forestall some of the target-organ damage of chronic kidney disease.
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Review
Preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications.
Postoperative pulmonary complications are among the most common sources of morbidity in patients undergoing major surgery. For this reason, the preoperative patient evaluation should emphasize risk factors for pulmonary complications as well as for traditional cardiac complications, as the former are comparably frequent and associated with longer hospital stays. ⋯ Pulmonary function testing has a limited role and should not be the basis for denying surgery if the surgical indication is compelling. Strategies to reduce the risk of postoperative pulmonary complications include optimizing management of chronic lung disease before surgery, lung expansion maneuvers, pain control, and selective placement of nasogastric tubes.
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Case Reports
Perioperative management of the bariatric surgery patient: focus on cardiac and anesthesia considerations.
Obesity is a major public health problem in developed nations worldwide. Currently, the only treatment for severe obesity (BMI > or = 35 kg/m2 with comorbidity) that provides long-term weight loss is bariatric surgery. Restrictive, malabsorptive, and combination procedures have been developed. ⋯ Candidates for bariatric surgery are often at high risk for complications because of obesity-related comorbidities. Therefore, careful patient selection for bariatric surgery, together with well-designed strategies for preventing and managing complications, are keys to success. Close monitoring for nutritional deficiencies and short- and long-term complications is required to completely assess outcomes of these procedures.