Minerva anestesiologica
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Dynamic indices (based on cardiopulmonary interactions in mechanically ventilated patients in sinus rhythm) have been developed as simple tools for predicting fluid responsiveness in the absence of cardiac output monitoring. Although the earliest dynamic indices relied on the invasive measurement of pulse pressure variations or stroke volume variations, the most recently developed indices are based on non-invasive photoplethysmography. However, a number of confounding factors have been found which decrease the clinical value of these indices. The present experts' opinion explains why changes in dynamic indices during hemodynamic maneuvers might be an interesting alternative to using them accurately at bedside.
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Minerva anestesiologica · Oct 2016
Randomized Controlled TrialThe effects of minimal-dose versus low-dose S-ketamine on opioid consumption, hyperalgesia, and postoperative delirium: a triple-blinded, randomized, active- and placebo-controlled clinical trial.
Evidence confirms that perioperative ketamine administration decreases opioid usage. To reduce the risk for potential psychodysleptic side effects, however, ketamine dosing tends to be limited to low-dose regimens. We hypothesized that even lower doses of ketamine would be sufficient, with minimal side effects, when used as a component of multimodal perioperative pain management. ⋯ Our data demonstrate that minimal-dose S-ketamine was comparable to the conventional low-dose regimen in reducing postoperative opioid consumption and hyperalgesia. Postoperative delirium, however, was less frequent with the minimal-dose regimen. We therefore suggest that minimal-dose S-ketamine may be a useful low-risk component of balanced perioperative analgesia.
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Minerva anestesiologica · Oct 2016
Observational StudyEffects of passive leg raising on microvascular venous compartment in critically ill patients.
Even though fluid loading is thought to improve organ perfusion, the way in which it does so remains unclear. We assessed how the microvascular bed in skeletal muscle reacts to passive leg raising in patients with and without sepsis or septic shock. ⋯ Our study provides evidence that macrocirculatory parameters are unreliable to derive measurements of stressed and unstressed volumes. Our results indicate that in septic shock, the enlargement of the unstressed volume associated with passive leg raising induces loss of fluids to the interstitium, thus leaving organ perfusion unchanged or worse.
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Minerva anestesiologica · Oct 2016
Case ReportsWhole-exome sequencing of a family with local anesthetic resistance.
Local anesthetics (LA) work by blocking sodium conductance through voltage-gated sodium channels. Complete local anesthetic resistance is infrequent, and the cause is unknown. Genetic variation in sodium channels is a potential mechanism for local anesthetic resistance. A patient with a history of inadequate loss of sensation following LA administration underwent an ultrasound-guided brachial plexus nerve block with a complete failure of the block. We hypothesized that LA resistance is due to a variant form of voltage-gated sodium channel. ⋯ We identified a genetic variant that is associated with LA resistance in the gene encoding for Nav1.5. We also demonstrate that Nav1.5 is present in human peripheral nerves to support the plausibility that an abnormal form of the Nav1.5 protein could be responsible for the observed local anesthetic resistance.