Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2012
ReviewStrategies to reduce the use of blood products: a European perspective.
Anemia is the most common hematologic problem preoperatively. In itself it compromises the outcome of surgical patients, and additionally results in more frequent allogeneic red blood cell (RBC) transfusions which again independently compromise patient outcome. In elective cardiac surgery as well as in other surgical specialties the use of a patient blood management program will minimize the exposure to blood products, lead to a cost reduction and improve patient's outcome. The aim of this review is to discuss the rationale for patient blood management, explain patient blood management in detail including modern and future transfusion strategies. ⋯ Patient blood management strategies are based on an interdisciplinary multimodal approach including early preoperative recognition and treatment of anemic patients, surgical efforts to minimize blood loss, optimal perfusion strategies to reduce hemodilution and continuous assessment of the bleeding and coagulation status of patients as well as a restrictive volume management. This allows specific and goal-directed treatment of patients, preventing anemia in elective patients, optimizing patient's coagulation status early, minimizing exposure to blood products, reducing costs and improving patient's outcome.
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Coagulation management remains a challenge for anesthesiologists involved in cardiovascular surgery as the population undergoing surgery becomes older and presents with more comorbidities. These patients are frequently treated with one or more agents that directly affect coagulation. This review will discuss what is known and the treatments available to manage coagulation in the perioperative setting of cardiac surgery. ⋯ The introduction of new drugs with different mechanisms of action adds to the complexity of coagulation management during cardiovascular surgery. Monitoring needs to be developed and improved, especially for evaluating platelet function.
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New anticoagulants and new techniques bring challenges and opportunities to the practice of anaesthesia. Existing guidelines may not be up-to-date with these changes, so this review will examine the current research with a view to identifying deficiencies in existing guidelines, particularly those that may guide Australian anaesthetists. ⋯ Despite much interesting recent research, few current guidelines are likely to require modification. Novel pharmaceuticals have risk profiles that are incompletely understood, but will only become evident on phase-4 testing. Australasian guidelines for reversal of warfarin may need to be updated to include advice on the use of recombinant factor 7a.
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Chronic obstructive pulmonary disease (COPD) is a common cause of primary hospital admission and also a common coexisting disease among surgical patients. This translational review focused on recent studies related to the perioperative care of COPD patients. ⋯ Perioperative management as well as modern intensive care concepts are based on avoidance of tracheal intubation if possible, use of regional anesthesia techniques and the early liberation from invasive mechanical ventilation. Noninvasive ventilation has become more and more utilized in recent years to stabilize patients with acute exacerbations of COPD and to treat postoperative pulmonary complications in order to avoid reintubation.
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Bleeding in a perioperative setting occurs due to multiple causes, but newer anticoagulant and antiplatelet therapies are increasingly used preoperatively. As a result, patients often can present for surgery with underlying hemostatic disorders due to these acquired disorders or following major surgery or trauma. Because bleeding occurs due to multiple causes, the addition of pharmacologic agents creates an acquired defect that complicates the surgical injury and may result in increased blood loss. An understanding of hemostasis and therapeutic approaches, especially those in our current clinical settings, is crucial in managing these patients. ⋯ Nonsurgical bleeding in the operating room is the result of a multitude of factors including preoperative anticoagulants, dilution, fibrinolysis, and factor consumption. Therapeutic prohemostatic pharmacologic approaches, in addition to standard transfusion therapy, need to be considered in the prevention and treatment of coagulopathy in surgical patients.