Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2009
ReviewPerioperative management of outpatients with implantable cardioverter defibrillators.
Implantable cardioverter defibrillators (ICDs) are increasingly being placed in patients worldwide. These patients pose significant perioperative challenges and are at an increased risk of complications; the suitability of ambulatory surgery in this patient population remains controversial. The purpose of the present review is to examine the potential challenges and optimal perioperative care of patients with an ICD. ⋯ Anesthesia practitioners involved in the care of patients with ICDs should familiarize themselves with the response to magnets application on ICD function as well as understand the situations in which magnet use is not advisable. Perioperative communication with the patient's cardiologist and surgeon is critical in reducing adverse outcome.
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Curr Opin Anaesthesiol · Dec 2009
ReviewPerioperative management of ambulatory surgical patients with diabetes mellitus.
Patients with diabetes frequently present for ambulatory surgery concomitant with the rise in incidence of the disease. This review will examine recent evidence on glucose control, the harmful effects of hyperglycemia, fluctuations of blood glucose, and hypoglycemia, as well as treatments and medications utilized for type 1 and type 2 diabetes mellitus. Based on this evidence, a strategy for perioperative decision making for the diabetic patient undergoing ambulatory surgery will be presented. ⋯ The ambulatory anesthesiologist, with a dedication to low-impact practices and emphasis on rapid recovery, provides an ideal environment of care for the patient with diabetes. This review will examine issues and concerns with management of the patient with diabetes undergoing ambulatory surgery and address them in a step-wise strategy for care, including recommendations for perioperative insulin administration.
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Cardiac output (CO) and other flow-based hemodynamic variables have become increasingly important to guide treatment of patients undergoing major surgery with expected fluid shifts in the operating room as well as critically ill ICU patients. Established techniques such as pulmonary artery thermodilution, however, might not be justified in all of these patients. As arterial access is commonly available, less-invasive arterial pressure waveform-based CO devices are becoming more and more popular. ⋯ Although there are differences in invasiveness and the need for external calibration, all available devices provide parameters for enhanced hemodynamic monitoring. Initial validation studies of the more established techniques such as the pulse contour cardiac output (PiCCO) or LiDCO were recently met with less enthusiasm, whereas the initially disappointing validation studies of the FloTrac/Vigileo device had encouraging results after software updates. The pressure recording analytical method (PRAM) technique has not so far been sufficiently evaluated to be able to come to a conclusion. Further investigation is required with regard to the ability of the arterial pressure waveform-based methods to guide goal-directed therapy.
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It is timely to review recent publications that add to our knowledge of malignant hyperthermia because we can go to the web or to newspapers and read of recent tragic malignant hyperthermia deaths. ⋯ Because malignant hyperthermia is potentially lethal, families should be evaluated as thoroughly as possible when an individual who claims to be malignant hyperthermia susceptible presents for elective surgery. Genetic testing may facilitate the evaluation of families with a very strong history of malignant hyperthermia. The use of activated charcoal can speed the removal of potent inhalation anesthetics from anesthesia workstations. This should facilitate the anesthetic care of malignant hyperthermia susceptible patients.
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The present review article provides a summary of the recent literature evaluating the technology for monitoring depth of anesthesia and patient outcomes associated with its use. ⋯ The goal of precisely dosed general anesthesia guided by brain monitoring remains elusive.