Current opinion in anaesthesiology
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The purpose of this review is to evaluate new concepts in mechanical ventilation in trauma. We begin with the keystone of physiology prior to embarking on a discussion of several new modes of mechanical ventilation. We will discuss the use of noninvasive ventilation as a mode to prevent intubation and then go on to airway pressure release ventilation, high-frequency oscillatory ventilation, and computer-based, closed loop ventilation. ⋯ The old modes of continuous positive airway pressure and bilevel positive airway pressure have been actively introduced in clinical practice in the case of trauma patients. Used with proper pain management protocols, there has been a decrease in the incidence of intubation in blunt thoracic trauma. Airway pressure release ventilation has been gaining a role in the management of thoracic injury and may lead to less incidence of physiologic trauma to mechanically ventilated patients. High-frequency oscillatory ventilation has been shown to be effective in patient care by its ability to open and recruit the lung in trauma patients and in those with acute respiratory distress syndrome but it may not have a role in patients with inhalational injury. Closed loop ventilation is a technology that may better control major pulmonary parameters and lead to more rapid titration from the ventilator to spontaneous breathing.
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Curr Opin Anaesthesiol · Apr 2010
ReviewHepatic encephalopathy: current management strategies and treatment, including management and monitoring of cerebral edema and intracranial hypertension in fulminant hepatic failure.
Hepatic encephalopathy is a syndrome whose pathophysiology is poorly understood, for which we lack high-quality diagnostic tests and markers, and whose treatment has improved only slightly over the last several decades. Serum ammonia levels remain the diagnostic gold standard. ⋯ Current diagnostic tests are imperfect, and modern therapy is nonspecific. No cost-efficient or more effective alternatives to either are likely to enter into clinical practice in the short-term future.
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To update readers on recent literature regarding treatment of coagulopathy for patients with life-threatening bleeding, highlighting emerging therapeutic options, controversial topics, and ongoing clinical trials. ⋯ Massive transfusion protocols standardize treatment of the coagulopathy of massive bleeding, leading to rapid restoration of hemostasis and decrease in early mortality.
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Curr Opin Anaesthesiol · Apr 2010
ReviewRenal failure in patients with cirrhosis: hepatorenal syndrome and renal support strategies.
The development of hepatorenal syndrome in liver cirrhosis leads to an increased morbidity and mortality in patients with cirrhosis. Currently, there are no proven methods for the treatment or prevention of hepatorenal syndrome except to maintain adequate hemodynamics and intravascular volume in this patient population. These patients will frequently require renal replacement therapy when presenting for hepatic transplantation. ⋯ Hepatorenal syndrome, HRS, is a diagnosis of exclusion. There are two forms of hepatorenal syndrome: type 1 hepatorenal syndrome and type 2 hepatorenal syndrome. Type 1 HRS is rapidly progressive and portends a very poor prognosis and has a high mortality rate. Type 2 is more indolent while still associated with an overall poor prognosis. Treatment of HRS is largely still supportive. It is imperative to maintain euvolemia and hemodynamics in this patient population to optimize renal perfusion and preserve renal function. Renal replacement therapy may be necessary in this chronically ill patient population, if renal function deteriorates such that the kidneys cannot maintain metabolic and volume homeostasis. Further research is still necessary as to the prevention and effective treatment for hepatorenal syndrome.
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Curr Opin Anaesthesiol · Apr 2010
ReviewStatus quo and current trends of operating room management in Germany.
Ongoing healthcare reforms in Germany have required strenuous efforts to adapt hospital and operating room organizations to the needs of patients, new technological developments, and social and economic demands. This review addresses the major developments in German operating room management research and current practice. ⋯ In the presence of increasing financial pressure, a hospital's executives need to empower an independent operating room management function to achieve the hospital's economic goals. Operating room managers need to adopt evidence-based methods also from other scientific fields, for example management science and information technology, to further sustain operating room performance.