Current opinion in anaesthesiology
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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.
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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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To describe the epidemiology, pathophysiology, diagnosis and management of perioperative acute kidney injury (AKI) in elderly patients. ⋯ Postoperative AKI incidence is expected to rise as the number of elderly patients undergoing surgery is increasing. Biomarkers of early AKI will likely be important for the future development and validation of novel treatment strategies. The haemodynamic management of the elderly surgical patient should focus on avoiding hypotension and high central venous pressures.
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Curr Opin Anaesthesiol · Apr 2015
ReviewConsiderations for anesthesia staffing in a trauma center: new standards, education, and safety.
A review of recent updates to trauma anesthesia service requirements in the USA and UK, the evolving role of the trauma anesthesiologist, and opportunities for education and training. Considerations of cost and safety for staffing arrangements are discussed. ⋯ There is a growing recognition that trauma anesthesiology represents a distinct area of subspecialty knowledge. Anesthesiology specialty organizations advocate for trauma-specific knowledge and training for trauma anesthesia providers. Requiring the in-house presence of anesthesia providers in level I and level II trauma centers may impose significant costs on medical centers that do not currently provide those services.
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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.