Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2015
ReviewStrategies to reduce blood transfusion: a Latin-American perspective.
Anemia has been demonstrated to be detrimental in several populations such as high-surgical-risk patients, critically ill elderly, and cardiac patients. Red blood cell transfusion is the most commonly prescribed therapy for anemia. Despite being life-saving, it carries a risk that ranges from mild complications to death. The aim of this review is to discuss the risks of anemia and blood transfusion, and to describe recent developments in the strategies to reduce allogeneic blood transfusion. ⋯ An adequate judgment of a clinical condition associated with proper application of the available literature is the cornerstone in the management of transfusion in critical care. Apart from this individualized strategy, the institution of a patient blood management program allows goal-directed approach through preoperative recognition of anemia, surgical efforts to minimize blood loss, and continuous assessment of the coagulation status.
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The mean age of patients presenting for thoracic surgery is rising steadily, associated with an increased demand for thoracic surgical treatments by geriatric patients. With increasing age, physiologic changes and comorbidities have to be considered. Thoracic anesthesia for elderly patients requires greater specific knowledge. ⋯ Considering key points of physiology and pharmacology can help to provide best possible care for the increasing number of elderly patients in thoracic surgery. Management of geriatric patients in thoracic surgery offer opportunities for anaesthetic interventions including protective ventilation, use of different anesthetics, anaesthesia monitoring, fluid management and pain therapy.
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Chest tube protocols are still largely dictated by personal preferences and experience. A general lack of published evidence encourages individual decision-making and hinders the development of clear-cut guidelines. The aim of this review is to establish standardized procedures with recommendations for size and number of inserted tubes, ideal suction levels and duration of thoracostomy. ⋯ Thoracic procedures are heterogeneous and postsurgical requirements vary in accordance. Most resections will not require more than one large bore (≥20F) catheter and will benefit from postoperative active suction. Even though only moderate-quality evidence suggests that suction reduces incidence of pneumothorax if compared to water seal and its effects on prolonged air leak are controversial, recent studies encourage application of active suction. Removal of chest tubes appears to be well tolerated even with a secretion of above 450 ml/day.
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Hypercapnia is a central component of diverse respiratory disorders, while 'permissive hypercapnia' is frequently used in ventilatory strategies for patients with severe respiratory failure. This review will present data from recent studies relating to hypercapnia, focusing on issues that are of importance to anesthesiologists caring for the surgical and/or critically ill patient. ⋯ The mechanisms of action of hypercapnia and acidosis continue to be elucidated, and this knowledge is central to determining the safety and therapeutic utility of hypercapnia in protective lung ventilatory strategies.
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Curr Opin Anaesthesiol · Feb 2015
Review Case ReportsPreoperative evaluation of the patient with lung cancer being considered for lung resection.
This review summarizes the general approach to evaluating the cardiopulmonary fitness of a patient with lung cancer being considered for lung resection. Many patients have a high risk for morbidity and mortality from lung resection owing to severe comorbidities or low cardiopulmonary reserve. A comprehensive and individualized assessment is essential to identify the factors that may impact operative outcome. ⋯ Preoperative assessment requires an understanding of the relative benefits and harms of available treatment options and consideration of patients' values. A balance between the potential to cure one's cancer and the short-term and long-term risks of the selected treatment needs to be reached. All patients should have a baseline FEV(1) and DL(CO) measured, and predicted postoperative FEV(1) and DL(CO) calculated to assist with risk prediction. Measures of exercise performance can help to further risk stratify patients. Means of modifying the risks should be considered for all patients.