Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2015
ReviewAcute trauma and multiple injuries in the elderly population.
Traumatic injuries in the rapidly growing elderly population pose a significant challenge to the healthcare community. These injuries are associated with significant morbidity and mortality, and as a result cause a financial burden on the medical system. Although normal decline in physiologic reserve can provide some explanation for these poor outcomes, there is significant room for improvement. This review will summarize recent literature around the evaluation and management of elderly trauma patients with a particular focus on those with hip fractures. ⋯ Differentiated, geriatric-specific triaging, assessment and treatment pathways in the care of elderly trauma patients will ultimately lead to improvements in outcomes. These improvements have already started to be seen in the realm of orthogeriatrics.
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To provide an overview of acquired coagulopathies that can occur in various perioperative clinical settings. Also described are coagulation disturbances linked to antithrombotic medications and currently available strategies to reverse their antithrombotic effects in situations of severe hemorrhage. ⋯ Targeted hemostatic therapy aims to correct coagulopathies in specific clinical settings, and reduce the need for allogeneic transfusions, thus preventing massive transfusion and its deleterious outcomes. Although there are specific guidelines for reversing anticoagulation in patients treated with antiplatelet agents or warfarin, there is currently little evidence to advocate comprehensive recommendations to treat drug-induced coagulopathy associated with new oral anticoagulants.
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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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There is recognition that the use of sedative drugs in critically ill patients is potentially harmful, particularly in relation to ICU delirium and clinical outcomes. In that context, there is an increasing interest in maintaining light sedation, the use of non-gamma-aminobutyric acid agonist agents and antipsychotics. ⋯ The bedside clinician needs to balance the need to sedate the patient and maintain life-saving support, while keeping their patient responsive, cooperative and pain free.
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Positive inotropic agents are widely used in the management of the critical ill patient presenting with low cardiac output state. Different inotropic agents are available, and different effects on hemodynamic endpoints may be recognized, but data on relevant clinical endpoints are scarce. A growing body of literature suggests that overuse of inotropes may have detrimental effects on cardiomyocytes, resulting in an increased risk of morbidity and mortality. The present review will summarize recent literature, focusing on outcome studies among adult patients related to use of inotropes in different clinical settings. ⋯ A 'less is more' approach may show to be appropriate when relating to routine use of inotropes. Inotropic therapy should be restricted to patients with heart failure and clinical signs of end-organ hypoperfusion.