Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2020
ReviewFascial plane blocks in thoracic surgery: a new era or plain painful?
The demand for well-tolerated, effective, and opioid reducing pain management has become imperative in thoracic surgery. With the recent movement away from neuraxial analgesia for thoracic surgical patients, great interest in alternative analgesic techniques of the chest wall has developed. Multiple fascial plane blocks have been developed for pain management of the lateral chest wall and we present an up-to-date review of these popular new interventions. ⋯ Fascial plane blocks hold the potential for well-tolerated and effective analgesia for thoracic surgical patients as part of a multimodal regimen of pain relief. However, many questions remain regarding block characteristics. As the literature matures, more formal recommendations will be made but quality trials are needed to provide this guidance.
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Curr Opin Anaesthesiol · Feb 2020
ReviewUltrasound-guided blocks for cardiovascular surgery: which block for which patient?
Regional anesthesia blocks may benefit patients undergoing cardiovascular surgery. This review coincides with the evolution of ultrasound-guided fascial plane blocks, societal concerns regarding opioid misuse and changing expectations regarding surgical recovery. ⋯ Ultrasound-guided fascial plane blocks may reduce postoperative opioid requirements. Investigation into the safety and efficacy of bilateral continuous ultrasound-guided blockade for cardiac surgery is required. Trial protocols should be embedded into enhanced recovery after surgery programs. Patient-reported and long-term outcomes are recommended.
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Ex-vivo lung perfusion (EVLP) has been developed to expand the donor pool for lung transplantation recipients. The role of EVLP in organ preservation, evaluation and potential reconditioning is reviewed. ⋯ EVLP has been shown to be an effective system to expand donor pool for lung transplantation without detriment to recipients. Future potential ex-vivo developments may further improve patient outcomes as well as increasing availability of donor organs.
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Hemodynamic instability is common in the perioperative period because of obligate physiologic changes that occur with surgery. Despite the frequency of such hemodynamic changes and the potential harm associated with them, particularly in the elderly, guidelines to optimize perioperative blood pressure are lacking. The present review examines recent evidence for perioperative blood pressure management in the elderly. ⋯ Precise and intentional management of hemodynamic parameters, medication regimens, and blood pressure monitoring may reduce adverse events in elderly patients undergoing surgery. Further investigation is required to identify the exact hemodynamic parameters that mitigate risk.
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Curr Opin Anaesthesiol · Feb 2020
ReviewPatients with left ventricle assist devices presenting for thoracic surgery and lung resection: tips, tricks and evidence.
Over a thousand left ventricular-assist device (LVAD) implants were performed for heart failure destination therapy in 2017. With increasing survival, we are seeing increasing numbers of patients present for noncardiac surgery, including resections for cancer. This article will review the relevant literature and guidelines for patients with LVADs undergoing thoracic surgery, including lung resection. ⋯ Successful thoracic surgery requires understanding of the LVAD physiology. Modern devices are preload dependent and afterload sensitive. The effects of one-lung ventilation, including hypoxia and hypercapnia, may increase pulmonary vascular resistance and impair the right ventricle. Successful surgery necessitates a multidisciplinary approach, including thorough preoperative assessment; optimization and planning of intraoperative management strategies; and approaches to anticoagulation, right ventricular failure and LVAD flow optimization. This article discusses recent evidence on these topics.