Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2014
ReviewFluid management in the cardiothoracic intensive care unit: diuresis - diuretics and hemofiltration.
The present review discusses the current concepts of fluid management in cardiothoracic surgery, and its clinical implications with special reference to organ-related complications and their prevention. ⋯ The optimal fluid management in cardiothoracic patients has not been settled. Results of recent clinical published trials highlight the need for minimizing fluid administration and attempting to use diuretics to achieve a negative fluid, although hypovolemia and hypoperfusion should be carefully considered. An individualized optimization of fluid status, using goal-directed therapy, has emerged as a possible preferable approach. The old debate between crystalloid and colloid solutions has been partially solved, as some colloids have demonstrated deleterious effect on renal function and coagulation system. Various preventive strategies have also emerged for minimizing fluid-related complications.
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Curr Opin Anaesthesiol · Apr 2014
Review Comparative StudyCost-efficiency of knowledge creation: randomized controlled trials vs. observational studies.
This article reviews traditional and current perspectives on randomized, controlled trials (RCTs) and observational studies relative to the economic implications for public healthcare stakeholders. ⋯ Considering the strengths and limitations of each study type, clinical researchers should explore the contextual worthiness of either design in promulgating knowledge. They should focus on quality of conduct and reporting that may allow for the liberation of limited public and private clinical research funding.
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Bleeding in trauma carries a high mortality and is increased in case of coagulopathy. Our understanding of hemostasis and coagulopathy has improved, leading to a change in the protocols for hemostatic monitoring. This review describes the current state of evidence supporting the use of viscoelastic hemostatic assays to guide trauma resuscitation. ⋯ We are moving toward avoiding coagulopathy by individualized, goal-directed transfusion therapy, using viscoelastic hemostatic assays to guide ongoing resuscitation of actively bleeding patients in a goal-directed manner.
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A large proportion of patients undergoing surgery have coexisting chronic kidney disease, placing them at greater risk of postoperative morbidity and mortality. The purpose of this review is to review the recent developments in how renal function is estimated, how this relates to surgical outcomes, and how this has been applied clinically. ⋯ Improved accuracy in defining kidney disease will aid clinicians in identifying higher risk patients, and aid earlier diagnosis of acute kidney injury. Further research is required, specifically on the implications of kidney disease in noncardiac surgical patients, and how defining renal function before and after surgery can aid in preventive strategies.
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Curr Opin Anaesthesiol · Apr 2014
ReviewPredicting postoperative pulmonary complications: implications for outcomes and costs.
This review of progress toward reliable prediction of postoperative pulmonary complications (PPCs) discusses risk assessment against the background of patient management strategies, clinical outcomes, and cost of healthcare. ⋯ PPCs are associated with a higher incidence of life-threatening events and higher costs. Reliable PPC risk-stratification tools are essential for guiding clinical decision-making in the perioperative period. The care team can act on modifiable factors and optimize vigilance over nonmodifiable ones. It would be useful to focus resources on determining whether low-cost preemptive interventions improve outcomes satisfactorily or new strategies need to be developed.