International anesthesiology clinics
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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.
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Int Anesthesiol Clin · Jan 1996
ReviewHypothermia-associated protection from ischemic brain injury: implications for patient management.
There is a large amount of experimental evidence that mild hypothermia in laboratory animals will protect the brain from ischemic injury. Conversely, mild hyperthermia will exacerbate injury. Supporting data in humans are limited. ⋯ Second, better methods are needed to monitor brain temperature during periods of risk for ischemic injury. And third, management techniques should be identified that will use brain-to-core temperature gradients to the patient's advantage, thus producing optimal alterations in brain temperature while minimally affecting systemic temperature and physiology. Before these goals can be accomplished, more research is needed, both in laboratory animals and in humans.
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We hope to have inspired an interest in approaching the pain management issues in this challenging group of patients. Despite significant progress in understanding the pathophysiology of pain, the development of therapeutic options, and the publication and dissemination of guidelines, this progress does not seem to have been adopted into clinical practice. Bonica has stated "for many years I have studied the reasons for inadequate management of postoperative pain, and they remain the same.... ⋯ The importance of understanding the specific benefits available and matching these characteristics to the particular patient is emphasized. Evaluation of outcomes, including morbidity and patient satisfaction, will determine if effective and rational provision of analgesia may indeed be safer than withholding analgesia. However, it is clear that re-evaluation and refinement of conventional therapy is necessary.