Current pharmaceutical design
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Underlying cardiovascular disease is a potentially modifiable risk factor that contributes significantly to perioperative morbidity and mortality. Reducing perioperative and long-term morbidity and mortality requires risk modifying perioperative management. This, in turn, requires preoperative identification of patients with, or at risk of having cardiovascular disease. ⋯ Not all of them can reliably be predicted or modified in a way which improves outcome. However, recognition of such factors and aggressive attempts at appropriate intervention may reduce overall risk more than preoperative evaluation in isolation. Without defining and subsequently targeting intra- and postoperative risk factors, the benefit of preoperative cardiac evaluation will be limited.
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The exact effect of opioid analgesics on sleep is to be determined. Although literature data are sporadically reported, the aim of this review is to summarize the already known effects of such medications on sleep. A variety of effects, both positive and negative, has been suggested, when opioids are used for pain treatment, but in the absence of pain as well. ⋯ Furthermore, several reports have shown significantly improved sleep quantity and adequacy, with reduced sleep disturbances. Still, as no prospective trials on the effect of opioid therapy on sleep are available and evidence is scarce, definitive conclusions cannot be drawn. Future studies with their effect on sleep as primary end-point are needed to draw permanent conclusions.
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Fospropofol is an intravenous sedative-anesthetic agent that is FDA-approved for monitored anesthesia care (MAC) sedation in adult patients undergoing diagnostic or therapeutic procedures. As a prodrug of propofol, fospropofol's pharmacologic activity results from its breakdown by alkaline phosphatase and release of propofol, which is the active molecule. It exhibits a longer time to peak clinical effect and a more prolonged action compared to propofol. ⋯ Available evidence demonstrates that fospropofol in MAC sedation is successful in patients undergoing esophagogastroscopy, colonoscopy and flexible bronchoscopy. The use of fospropofol is also now being explored in many other perioperative settings. In light of current shortages of many anesthetic drugs, whether forspropofol can take the place of propofol in ICUs and operating rooms remains to be determined.
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An array of clinical events may lead to perioperative neurological injury. We first review the general cellular mechanisms leading to brain tissue injury and death. ⋯ More has become known about the epidemiology, risk factors and potential preventive strategies in postoperative delirium, and, to a lesser extent, postoperative cognitive dysfunction. Finally, emerging concepts in clinical brain protection are discussed, including preconditioning, gene therapy and stem cells.
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Review
Prevention of immune-mediated transfusion-related acute lung injury; from bloodbank to patient.
Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion related morbidity and mortality. Immune-mediated TRALI is caused by leucocyte and neutrophil antibodies in the transfused blood products that react with white blood cell antigens of the recipient, hereby inducing endothelial damage and lung injury. About two thirds of TRALI cases are thought to be immune-mediated. ⋯ Another strategy involves dilution of antibodies present by pooling of plasma donations of multiple donors. From a bedside view, the most important measure to prevent TRALI is to limit patients' exposure to allogenic bloodproducts. Furthermore recognition and awareness of the syndrome need to be heightened among clinicians.