Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2017
ReviewDiagnosis of cardiac surgery-associated acute kidney injury from functional to damage biomarkers.
Acute kidney injury (AKI) occurs in up to 30% after cardiac surgery and is associated with adverse outcome. Currently, cardiac surgery-associated acute kidney injury (CSA-AKI) is diagnosed by Kidney Disease: Improving Global Outcomes criteria based on creatinine and urine output. To detect and treat AKI earlier, various biomarkers have been evaluated. This review addresses the current position of the two damage biomarkers neutrophil gelatinase-associated lipocalin (NGAL) and [TIMP-2] [IGFBP7] in clinical practice. ⋯ NGAL and urinary [TIMP-2] [IGFBP7], in combination with pretest assessment, are promising tools for early detection and treatment in CSA-AKI.
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Ventilator-induced lung injury is a major contributor to perioperative lung injury. The end-expiratory lung volume, regional lung overdistension, and tidal recruitment are known to be the main factors causing subsequent alveolar damage and inflammation. The alveolar-capillary membrane including the endothelial glycocalyx as an integral part of the vascular endothelium seems to play a major role in different kinds of lung injury. ⋯ This review focuses on the involvement of the pulmonary endothelial glycocalyx in the context of perioperative lung injury. The pathophysiological mechanisms and trigger factors of glycocalyx deterioration are discussed, and prevention strategies are taken into consideration.
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Curr Opin Anaesthesiol · Feb 2017
ReviewTherapy of acute kidney injury in the perioperative setting.
The current review analyzes the current pharmacologic approaches in cardiac surgery-associated acute kidney injury and renal replacement/support therapies. ⋯ Cardiac surgery is responsible for the highest risk of renal dysfunction with respect to other surgical settings. A number of different and coacting insults, including toxins, renal hypoperfusion, ischemia-reperfusion injury, and systemic inflammation, are leading causes of this frequent complication. Intense research is ongoing on the treatment of established cardiac surgery-associated acute kidney injury and, in this view, a holistic approach including preoperative data, risk stratification, prevention, timely diagnosis, and aggressive intervention can limit the burdening consequences of renal dysfunction in these patients. Although no specific pharmacologic and nonpharmacologic strategy can be currently recommended outside clinical research, the prompt identification of renal dysfunction and the application of multimodal treatments are fundamental aspects. Right ventricular dysfunction and increased central venous pressure, frequently affecting cardiac surgery patients, potentially lead to congestive renal dysfunction. Hemodynamic management covers a central role in these cases.
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Curr Opin Anaesthesiol · Feb 2017
ReviewSingle-lung ventilation and oxidative stress: a different perspective on a common practice.
To summarize what is currently known about the relationship between single-lung ventilation (SLV), oxidative stress, and postoperative disruption of organ function. ⋯ SLV and subsequent re-expansion of atelectatic lung are associated with the generation of reactive oxygen and nitrogen species that may modulate persistent systemic effects.
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Enhanced recovery after surgery (ERAS) methodology has demonstrated consistent benefits in patients undergoing colorectal, urological and thoracic surgeries. Principles of these protocols and their advantages are expected to extend into other surgical specialties such as bariatric surgery. In this review, we summarize the components of ERAS protocols for bariatric surgery and present the evidence on the emerging role of ERAS principles in obese patients. ⋯ ERAS for bariatric surgery is in its early phase. Nevertheless, literature supports its role in improving perioperative outcomes compared with conventional care in this scenario. Evidence-based protocols, multidisciplinary teamwork and meticulous audit seem to be the key factors for success in ERAS methodology.