Current opinion in critical care
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Curr Opin Crit Care · Aug 2012
ReviewEnhanced recovery pathways as a way to reduce surgical morbidity.
The aim of this review is to summarize important publications in enhanced recovery during 2010-2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome. ⋯ Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.
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Curr Opin Crit Care · Aug 2012
ReviewDescending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management.
The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available. ⋯ With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.
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To identify the recent literature supporting the ability of anesthesiologists to impact morbidity and mortality outside of the immediate intraoperative period. ⋯ Anesthesiologists should consider implication of goal-directed therapy in high-risk surgical patients, adhere to the American College of Cardiology/American Heart Association guidelines with regard to perioperative β-blockade, critically assess the data to support their choice of synthetic colloids over crystalloids, explore all possible strategies for avoiding perioperative transfusion, and be cognizant of their potential contribution to perioperative infectious morbidity.
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Curr Opin Crit Care · Aug 2012
ReviewImportance of intravenous fluid dose and composition in surgical ICU patients.
This review discusses the importance of intravenous fluid dose and composition in surgical ICU patients. On the basis of updated physiologic postulates, we suggest guidelines for the use of crystalloids and colloids. Goal-directed fluid therapy is advocated as a means for avoiding both hypovolemia and hypervolemia. ⋯ The routine replacement of unmeasured presumed fluid deficits is not appropriate. In critically ill patients, resuscitation with intravenous fluids should produce a demonstrable enhancement of perfusion. Individualized goal-directed therapy using functional hemodynamic parameters can optimize resuscitation and 'deresuscitation'.
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Surgical incision invariably causes some measure of nerve damage and inflammatory response that, in most cases, heals quickly without long-term negative consequence. However, a subset of these patients go on to develop lasting neuropathic pain that is difficult to treat and, in many cases, prevents the return to normal activities of life. It remains unknown why two patients with identical surgical interventions may go on to develop completely divergent pain phenotypes or no pain at all. Aggressive, early analgesic therapy has been shown to reduce the incidence of chronic postsurgical pain (CPSP), but no specific regional anesthetic technique or systemic pharmacologic therapy has been shown to prevent CPSP. ⋯ Here, we discuss the causes of CPSP and current useful preventive strategies in the perioperative period. We also discuss future potential disease-modifying treatments of CPSP.