Minerva anestesiologica
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Minerva anestesiologica · Oct 2017
Randomized Controlled TrialUltrasound-determined landmarks decreases pressure pain at epidural insertion site in immediate postpartum period.
Women have blamed epidurals for their post-partum back pain for decades. Survey-based studies have shown similar incidence of chronic back pain between women who delivered with epidurals compared to those who did not. However, epidural insertion site pain has yet to be evaluated by a quantitative measure: pressure pain threshold (PPT). Algometer measured PPT has been shown to be accurate and reproducible in acute, chronic, and postoperative pain studies. This study determines the effect of ultrasound-based landmarks on the PPT at the epidural insertion site in the post-partum period. ⋯ We showed that epidural placed with ultrasound-determined landmarks not only improves the success of epidural placement but also minimizes the number of intervertebral levels with decreased PPT.
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Minerva anestesiologica · Oct 2017
ReviewBrain monitoring in adult and pediatric ECMO patients: the importance of early and late assessments.
Monitoring brain integrity and neurocognitive function is a new and important target for the management of a patient treated with extracorporeal membrane oxygenation (ECMO), in particular because of the increasing awareness of cerebral abnormalities that may potentially occur in this setting. Continuous regular monitoring, as well as repeated assessment for cerebral complications has become an essential element of the ECMO patient management. Besides well-known complications, like bleeding, ischemic stroke, seizures, and brain hypoperfusion, other less defined yet relevant injury and clinical manifestations are increasingly reported and impacting on ECMO patient prognosis at short term. ⋯ Despite increasing awareness of these aspects, generally accepted protocols and clinical management strategies in this respect are still lacking. Current means to monitor brain perfusion or detecting ongoing cerebral tissue injury are rather limited, and most techniques provide indirect or post-insult recognition of irreversible tissue injury. Continuous monitoring of brain perfusion, serial assessment of brain-derived serum biomarkers, timely neuro-imaging, and post-discharge counselling for neurocognitive dysfunction, particularly in pediatric patients, are novel pathways focusing on neurologic assessment with important implications in daily practice to assess brain function and integrity not only during the ECMO-related hospitalization, but also at long-term to re-evaluate the neuropsychological integrity, although well designed studies will be necessary to elucidate the cost-effectiveness of these management strategies.
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Mechanical ventilation is a cornerstone of the intraoperative management of the surgical patient and is still mandatory in several surgical procedures. In the last decades, research focused on preventing postoperative pulmonary complications (PPCs), both improving risk stratification through the use of predictive scores and protecting the lung adopting so-called protective ventilation strategies. The aim of this review was to give an up-to-date overview of the currently suggested intraoperative ventilation strategies, along with their pathophysiologic rationale, with a focus on challenging conditions, such as obesity, one-lung ventilation and cardiopulmonary bypass. ⋯ Due to the high number of surgical procedures performed daily, the impact on patients' health and healthcare costs can be relevant, even when new strategies result in an apparently small improvement of outcome. A protective intraoperative ventilation should include a low tidal volume of 6-8 mL/kg of predicted body weight, plateau pressures ideally below 16 cmH2O, the lowest possible driving pressure, moderate-low PEEP levels except in obese patients, laparoscopy and long surgical procedures that might benefit of a slightly higher PEEP. The work of the anesthesiologist should start with a careful preoperative visit to assess the risk, and a close postoperative monitoring.
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Minerva anestesiologica · Oct 2017
ReviewContinuous regional anesthesia: a review of perioperative outcome benefits.
Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. ⋯ To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.