Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2009
ReviewUpdate on the role of paravertebral blocks for thoracic surgery: are they worth it?
To consider optimal analgesic strategies for thoracic surgical patients. ⋯ There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.
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Epidurals have been used for cardiac surgery for more than 20 years. The worldwide-published use is now large enough to determine that there is no additional risk for epidural use in cardiac versus noncardiac surgery. ⋯ Fear of an increased risk of epidural haematoma has largely prevented increased use of this technique for cardiac surgery. Clinicians can be reassured that the risk of epidural use in cardiac surgery is similar to that for noncardiac surgery, which provides a new platform for considering risk versus benefit in their practice.
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Interventional pulmonology is a rapidly expanding field offering less invasive therapeutic procedures for significant pulmonary problems. Many of the therapies may be new for the anesthesiologist. Although less invasive than surgery, some of these procedures will carry significant risks and complications. The team approach by anesthesiologist and pulmonologist is key to the success of these procedures. ⋯ This review is intended to familiarize the anesthesiologist with current and rising therapeutic modalities for pulmonary disease. Knowledge of interventional pulmonology facilitates planning and preparation for well tolerated and effective procedures.
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Curr Opin Anaesthesiol · Feb 2009
ReviewUpdate on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia.
This review is focused on tracheobronchial anatomy and the use of flexible fiberoptic bronchoscopy in thoracic anesthesia. ⋯ Recognition of tracheobronchial anatomy and familiarity with the use of flexible fiberoptic bronchoscope are key components while managing patients undergoing thoracic surgery and anesthesia.
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The primary goal of hemodynamic therapy is the prevention of inadequate tissue perfusion and inadequate oxygenation. Advanced cardiovascular monitoring is a prerequisite to optimize hemodynamic treatment in critically ill patients prone to cardiocirculatory failure. The most ideal cardiac output (CO) monitor should be reliable, continuous, noninvasive, operator-independent and cost-effective and should have a fast response time. Moreover, simultaneous measurement of cardiac preload enables the diagnosis of hypovolemia and hypervolemia. ⋯ Minor invasive arterial thermodilution is the standard for the estimation of CO. Less invasive and continuous techniques such as pulse-contour CO and arterial waveform analysis are preferable. The accuracy of noncalibrated pulse-contour analysis is still a matter of discussion, although recent studies demonstrate acceptable accuracy compared with a standard technique. Doppler techniques are minimally invasive and offer a reasonable trend monitoring of CO. Noninvasive continuous techniques such as bioimpedance and bioreactance require further investigation.