Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2013
ReviewControversies in pediatric anesthesia: sevoflurane and fluid management.
To explore the interrelationships among the pharmacokinetics of sevoflurane, epileptiform electroencephalographic (EEG) activity and awareness in children. To also describe the revised perioperative fluid management strategy espoused by Holliday and Segar and noninvasive measures that may predict who will respond positively to fluid loading. ⋯ Sevoflurane is a well tolerated induction agent that rarely causes seizures in children, but may cause awareness if the inspired concentration is prematurely reduced. Perioperative isotonic fluids should be infused at 20-40 ml/kg over 2-4 h during elective surgery. Noninvasive metrics do not predict a child's responsiveness to fluid loading.
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Curr Opin Anaesthesiol · Jun 2013
ReviewMaintaining micturition in the perioperative period: strategies to avoid urinary retention.
Maintaining micturition in the perioperative period can be challenging because of its low profile, other competing clinical criteria, poorly defined diagnostic criteria, and varying management strategies. Postoperative urinary retention, the main complication of micturition difficulties, has clinical implications in terms of perioperative outcome such as delayed discharge, iatrogenic infection from catheterization with the potential risk of systemic infection, and possible long-term bladder dysfunction. Factors contributing to postoperative micturition problems are multifactorial and anesthesiologists should consider the strategies to minimize the incidence of postoperative urinary retention. ⋯ Employing strategies aimed at minimizing the disruptions in bladder function can mitigate perioperative micturition problems and subsequent complications. This requires a multifactorial approach. We present identified risk factors, considerations for their modification, as well as a classification and management strategy that incorporates the literature to date.
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To keep pediatric anesthesiologists up-to-date in their management of pediatric emergencies by identifying the key publications from 2012 that are relevant to the anesthetic management of common pediatric emergencies. ⋯ Many areas of the management of pediatric emergencies remain controversial and based on little good evidence. In spite of this, the complication rate is low. Postoperative pain is an emerging problem while the optimal management of the full stomach is still unresolved.
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Different techniques and interventions that can be used by an anaesthesiologist to minimize the perioperative stroke risk are summarized. ⋯ Perioperative stroke increases morbidity and mortality of patients undergoing surgery and is therefore highly relevant. Neuromonitoring should be used to detect a deterioration of cerebral blood flow and oxygen supply immediately. Statins which are initiated at least 2 weeks before the operation can possibly reduce the perioperative stroke rate. Routinely taken statins should not be terminated and this is also true for β-blockers. The cerebral perfusion pressure should be kept at baseline levels, whereas a mild hypercapnia theoretically could be beneficial. Hypoglycemia has to be avoided while treatment of high blood glucose levels should be started when they exceed 150 mg/dl. The anesthesia for patients with a high risk for stroke has always to be performed by an experienced anaesthesiologist who is able to individualize the therapeutic interventions.
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Key elements in the initial resuscitation and stabilization of the patient with sepsis are fluid therapy, vasopressor or inotropic support, administration of adequate antibiotics and source control. This review will primarily discuss fluid, vasopressor and antibiotic therapy because these have been the subject of the recent large clinical trials. ⋯ Recent high-quality trials in the intensive care setting have provided data to improve the treatment and thereby the outcome of patients with sepsis. These findings may be used in the perioperative setting to minimize the harmful effects of specific interventions.