International anesthesiology clinics
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Int Anesthesiol Clin · Jan 1996
ReviewAssessment of sedation, analgesia, and neuromuscular blockade in the perioperative period.
Identification of adequate pain relief, sedation, and neuromuscular blockade in the perioperative period (be it for monitored anesthesia care, conscious sedation, ICU analgesia or sedation, or during intraoperative care) continues to be a challenge. Current subjective and objective techniques have been reviewed. The combination of clinical judgement, physiological response, and selected monitoring tools provide the current standard of care used to optimize patient care and comfort. Future directions in assessing pain control, adequacy of sedation, and degree of neuromuscular blockade include: (1) simplified scoring scales, (2) computerized analysis of the EEG, (3) computerized evoked potentials, (4) portable accelerography of electromyography for determination of neuromuscular blockade, and (5) closed loop system for delivery of analgesics, sedatives, and paralytics.
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A number of anesthetic agents have significant cerebroprotective potential and alter ischemic tolerance in vivo, at least within specific experimental conditions such as focal or incomplete, global cerebral ischemia. As compared to the unanesthetized state, each of these agents has some influence on CBF and metabolism, and many have significant effects on vascular responses to dilator stimuli. Relevant studies that provide clues to the mechanisms of anesthetic action in brain injury have been reviewed, and it is likely that these mechanisms are multifactorial and may overlap from one class of agents to another. Lastly, there is a clear need for further studies that specifically evaluate the neuroprotective mechanism of each agent, determine the effect on outcomes when the anesthetic is administered only as a posttreatment at clinically relevant concentrations, and compare anesthetics with the unanesthetized state when possible.
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Int Anesthesiol Clin · Jan 1996
ReviewMethods for monitoring hemostasis during and following cardiac surgery.
The challenges in cardiac surgical hemostasis continue to plague the clinician. Rapid analysis and interpretation of coagulation tests are crucial in identifying coagulopathies that include both hemorrhagic and thrombophilic conditions. ⋯ The coagulation tests that provide the most useful information include both end-point determinants and kinetic tests of clot formation. Future evaluation of the efficacy of coagulation tests in meeting these challenges will move beyond quantification of changes within various intermediates of hemostasis and rest with the correlation of these measured values with specific, outcome-directed indicators for optimizing patient care.
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Int Anesthesiol Clin · Jan 1996
ReviewRenal considerations, dialysis, and ultrafiltration during cardiopulmonary bypass.
Patients with preoperative renal insufficiency are more likely to develop postoperative renal failure than those with normal preoperative renal function. Both of these groups may benefit from optimizing intraoperative renal perfusion because not all preoperative renal risk factors are easily diagnosed. ⋯ Modified ultrafiltration studies suggest that ultrafiltration post-CPB can improve postoperative patient outcomes and that the mechanism for these improvements involve more than excess water removal. Since there are no contraindications for ultrafiltration or dialysis during CPB, the decision to use these techniques depends on the perceived potential benefits and the cost of adding a component to the CPB circuit.