Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2010
ReviewUse of clotting factors and other prohemostatic drugs for obstetric hemorrhage.
To guide the optimal use of blood products and to clarify the indications for prohemostatic drugs in obstetric hemorrhage. ⋯ It seems reasonable to use blood products for transfusion earlier and in a 1: 1 fresh frozen plasma: red blood cell ratio during acute obstetric hemorrhage; however, this analysis is mainly based on trauma literature. Fibrinogen concentrate should be added if the fibrinogen plasma level remains below 1.0 g l(-1) and perhaps even as soon as it falls below 1.5-2.0 g l(-1); the addition of tranexamic acid (1 g) is cheap, likely to be useful and appears safe. Data on the proactive administration of platelets are insufficient to recommend this practice routinely. Presently, recombinant factor VIIa (60-90 microg kg(-1)) is advocated only after failure of other conventional therapies, including embolization or conservative surgery, but prior to obstetric hysterectomy. Prospective randomized controlled trials are highly desirable.
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One of the newest strategies to enlarge the pool of organ donors is to consider the category of donors after cardiac death rather than only after brain death. Prompt and accurate identification of potential donors and appropriate care is necessary to optimize the management of nonheartbeating donors. ⋯ In order to increase the number of organs available for transplantation, donation from nonheartbeating donors has been recently proposed. Identification of the key aspects of the donation after cardiac death should be fully achieved by the team involved in the transplantation program. Development of hospital policies and identification of receivers who are most likely to benefit from this strategy require further studies to assess long-term outcome and to identify ethical aspects concerning different religious and cultural backgrounds.
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Curr Opin Anaesthesiol · Jun 2010
ReviewAnesthetic management of the patient with epilepsy or prior seizures.
Epilepsy is a clinical disorder of paroxysmal recurring seizures, the diagnosis excluding alcohol or drug withdrawal seizures or such recurring exogenous events as repeated insulin-induced hypoglycemia. Epilepsy has a profound impact on each individual diagnosed with this disease. ⋯ The primary concerns for providing anesthesia to the patient with epilepsy are the capacity of anesthetics to modulate or potentiate seizure activity and the interaction of anesthetic drugs with AEDs. Proconvulsant and anticonvulsant properties have been reported for virtually every anesthetic such that these properties become elements of the anesthetic plan in the patient with epilepsy. Moreover, AEDs have many physiologic and pharmacologic effects that can have an impact on an anesthetic.
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Curr Opin Anaesthesiol · Jun 2010
ReviewInside the black box: current policies and concerns with the United States Food and Drug Administration's highest drug safety warning system.
To evaluate the United States Food and Drug Administration use of the black-box warning system to promote drug safety and to examine the droperidol black-box warning as a case study. ⋯ Rather than relying on well conducted clinical investigations, the Food and Drug Administration subjectively issued a black-box warning to droperidol, which effectively removed droperidol from clinical practice for the indication of postoperative nausea and vomiting. Newer data suggest that the incidence of prolongation of the QT interval and the occurrence of torsades de pointes is similar to more expensive alternative medications used to treat postoperative nausea and vomiting.