Current opinion in anaesthesiology
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For 20 years, an alternative view of the universe has been available for acid-base physiology. The Stewart approach emphasizes mathematically independent and dependent variables. With the Stewart approach bicarbonate and hydrogen ions are dependent variables that represent the effects rather than the causes of acid-base derangements. Neither bicarbonate nor pH can be regulated directly; rather they are controlled by the independent variables. In plasma there are three independent variables: the partial pressure of carbon dioxide, strong ion difference, and weak acids. In plasma, sodium and chloride are the principal strong ions, and albumin is the principal weak acid. Critically ill patients often have changes in these variables. ⋯ The Stewart approach to acid-base physiology continues to develop as a comprehensive method to diagnose and manage acid-base disorders.
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The concept of involving pediatric patients in medical decision-making, in both clinical and research anesthesia and surgical care, has support from specialists involved in pediatric care. Production pressure in the workplace creates conflict between ethical anesthesia practice - such as obtaining informed consent - and time efficiency. Specialized documentation of anesthesia consent may increase efficiency but could weaken the consent process. Concerns with cost containment have led to interventional quality improvement activities that may constitute research and therein require informed consent. This review discusses these three consent issues as they relate to anesthesia care. ⋯ Anesthesiologists have ethical obligations to involve children in the medical decision-making process as much as the child's capacity allows, and to place patient advocacy in the informed consent process above production pressures. While a specific and separate anesthesia informed consent form may be useful, it should not undermine the process of informed consent or relegate the consent process to non-physician personnel. The informed consent process for anesthesia care remains the province and responsibility of the individual anesthesiologist.
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As surgical procedures become less invasive and medical procedures become more invasive, the role of procedural sedation has become more important. The resulting proliferation of settings for procedural sedation and providers rendering sedation has brought attention to the economics of this service from nonanesthesia specialists and payers. Rapidly escalating expenditures for sedation have led to scrutiny from public and private insurance carriers. The review will summarize these trends and predict changes in coding and payment for procedural sedation. ⋯ Coding, payment rules and fees for procedural sedation are likely to change in the coming 2-5 years. Those responsible for providing such services must consider the economic, clinical and workforce issues underlying these changes when planning to undertake or expand a commitment to sedation.
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Although enthusiasm of intensivists has been raised during the last 2-3 years due to several successful clinical trials, severe sepsis and septic shock still have an increasing incidence with more or less unchanged mortality. Within the last 12 months, the progress in sepsis research covering definitions, epidemiology, pathophysiology, diagnosis, standard and adjunctive therapy, as well as experimental approaches is encouraging. In this review, state-of-the-art publications of 2003 are presented to elucidate the possible impact on clinical routine. ⋯ Scientific progress in areas of sepsis has been continuing throughout 2003, although the challenges are still enormous. The identification of more specific markers and new therapeutic approaches will hopefully improve the diagnosis, monitoring of therapy, and outcome in the septic patient.
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An update on recent developments in diagnosis and treatment of disseminated intravascular coagulation. ⋯ Whereas antithrombin and tifacogin failed to improve clinical outcome in severe sepsis, drotrecogin alpha (activated) increased the chances of survival of patients with severe sepsis with and without disseminated intravascular coagulation.