Current opinion in anaesthesiology
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Sepsis, defined by the presence of infection and host inflammation, is a lethal clinical syndrome with an increasing mortality rate worldwide. In severe disease, the coagulation system becomes diffusely activated, with consumption of multiple clotting factors resulting in disseminated intravascular coagulation (DIC). When present, DIC portends a higher mortality rate. Understanding the mechanisms that tie inflammation and diffuse thrombosis will allow therapeutic interventions to be developed. The coagulopathy of acute sepsis is a dynamic process that is time and disease burden specific. Whole-blood testing of coagulation may provide more clinically useful information than the classical tests. Natural anticoagulants that regulate thrombosis are downregulated in sepsis. Patients may benefit from the modulation of the coagulation system when systemic inflammation and hypercoagulopathy exist. Proper timing of anticoagulant therapy may ultimately lead to decreased incidence of multisystem organ dysfunction. ⋯ The prevention of DIC in septic patients is a key therapeutic target in preventing death from multisystem organ failure. Stratifying patients for therapy using thromboelastometry, specific markers for DIC, and composite scoring systems is an area of growing research.
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Optimizing hemostasis with antifibrinolytics is becoming a common surgical practice. Large clinical studies have demonstrated efficacy and safety of tranexamic acid (TXA) in the trauma population to reduce blood loss and transfusions. Its use in patients without pre-existing coagulopathies is debated, as thromboembolic events are a concern. In this review, perioperative administration of TXA is examined in nontrauma surgical populations. Additionally, risk of thromboembolism, dosing regimens, and timing of dosing are assessed. ⋯ As part of a perioperative blood management programme, TXA can be used to help reduce blood loss and mitigate exposure to blood transfusion.
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Curr Opin Anaesthesiol · Apr 2015
ReviewResidents' scholarly activity: a cost analysis with regard to its effects on departments.
Current financial strain on training departments may have a significantly negative impact on continuing support for residents' scholarly activity. A cost analysis with regard to residents' scholarly activity effects on anesthesiology training departments is performed. ⋯ The importance of resident scholarly activity has never been so or as critical as in the present. Anesthesiology leadership must continue to invest to support resident scholarly activity for the future of the specialty while being mindful of costs incurred.
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Stress and burnout have arisen as relevant problems to the healthcare workers and the health systems themselves. As anaesthesiologists work in stressful areas of the hospitals, we are exposed to these problems. In this review, we summarize recent studies regarding stress and burnout, exploring possible solutions. ⋯ There is a lack of definitive evidence to guide the management of stress and burnout in medical professions in general and in anaesthesiology in particular. Longitudinal and interventional studies are needed to better determine ways of action. In the meantime, creating a positive work climate and institutional support as well as promoting control over one's job and the autonomy of employees are the most recommended strategies. Workers should also learn how to cope with stressors and practice personal strategies of wellness and resilience to fight against burnout.
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Growth in critical care services has led to a dramatic increase in the need for ICU physicians. The supply of intensivists is not easily increased and there is pressure to solve this problem by increasing the number of patients per intensivist. There is a scarcity of published data addressing this issue, and until recently, there were no guidelines on appropriate ratios of intensivists to patients. ⋯ The complex nature of critical care patients and ICUs make it difficult to provide one specific maximum intensivist-to-patient ratio, but common-sense rules can be applied. These recommendations are predicated on the principles that staffing can impact patient care as well as staff well-being and workforce stability. Also, that worsening patient outcomes, teaching, and workforce issues can be markers of inappropriate staffing. Finally, if the predicted daily workload of an intensivist exceeds the time of a work shift, then adjustments need to be made.