Minerva anestesiologica
-
Minerva anestesiologica · Jul 2018
Novel applications of bedside monitoring to plumb patient hemodynamic state and response to therapy.
Hemodynamic monitoring is essential during the treatment of the critically ill in order to address the hemodynamic alterations and assess the response to treatment. Traditionally classified causes of shock and underlying pathophysiological mechanisms are often neglected by resuscitative strategies included in the guidelines. Most of hemodynamic management focuses on the ability to early recognize patients susceptible to increase cardiac output (CO) and mean arterial pressure (MAP) after a defined fluid challenge by eliciting Starling's law of the heart, and less is known of the ones presenting in shock and not volume responsive. ⋯ More recently, pathophysiological and echocardiographic-based approaches have been introduced to investigate ventriculo-arterial coupling, the relationship between both left and right heart and the relative circulatory bed. Such techniques allowed establishing that in many critically ill scenarios, coupling between the heart and the circulation is inefficient and probably that is the reason why in this case hemodynamic restoration cannot be achieved by standard approaches. Combining echocardiography to better understand and treat in real-time pathophysiological determinants of altered hemodynamic states with functional approaches seems to be the key to plumb hemodynamic states although it remains to be demonstrated if this tailored approach will improve patient outcome.
-
Minerva anestesiologica · Jul 2018
Preliminary experience with epidural and perineural catheter localization with pulsed wave Doppler ultrasonography.
Various methods for peripheral nerve and epidural catheter location assessment exist, with varying degrees of ease of use, utility, and accuracy. Pulsed wave Doppler (PWD) evaluates the presence of fluid flow and is possible modality to assess the location of a percutaneously inserted perineural catheter. ⋯ Our preliminary experience with PWD ultrasonography suggests that they may offer the ability to selectively assess flow at different locations to identify the proper location of epidural and perineural catheters. Future randomized, controlled investigations are warranted to further evaluate the effectiveness and safety of this modality.
-
Minerva anestesiologica · Jul 2018
Current evidence for central analgesic effects of NSAIDs: an overview of the literature.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for a variety of painful conditions. Their peripheral anti-inflammatory effect due to inhibition of prostaglandin synthesis is well documented. In the late 1980's, animal data suggested for the first time that NSAIDs might have central effects as well. ⋯ Relevant mechanisms that underlie this central action involve spinal upregulation of the enzyme cyclooxygenase, increased spinal prostaglandin E2 production, modulation of inhibitory fast synaptic currents in lamina I and II of the dorsal horn, and glycine-dependent modulation of pain. Results from animal models are not yet sufficiently supported by human studies. This does not necessarily imply that the central effects of NSAIDs are irrelevant to human pain, but rather that methodological and regulatory barriers are the limiting step to translating findings from animal studies to human research protocols.