Minerva anestesiologica
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Minerva anestesiologica · Aug 2014
Randomized Controlled Trial Multicenter StudyColloids for fluid resuscitation: what is their role in patients with shock?
Fluid therapy is widely used in critically ill patients to restore effective intravascular volume and improve organ perfusion. Recent studies have questioned the administration of colloid-based solutions, especially if containing hydroxyethyl starch (HES), in different ICU populations; however, there is still uncertainty on the use of colloids as initial fluid therapy for early resuscitation. ⋯ These data suggest that mortality was not increased and probably decreased with the use of colloids in different forms of shock requiring early fluid resuscitation. We discussed herein some methodological issues that may explain the discrepancies of this trial with the other studies developed in the same field.
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Minerva anestesiologica · Aug 2014
ReviewSedation after cardiac arrest and during therapeutic hypothermia.
Mild therapeutic hypothermia (MTH) has improved neurological outcome of comatose patients after cardiac arrest (CA). Since the first clinical studies performed in this setting, sedation has always been associated with cooling procedures. The use of sedative drugs during MTH is required because it allows faster achievement and better maintenance of target temperature. ⋯ No differences in clinical outcomes have been found among different drugs, except for those related to their intrinsic pharmacological properties: the association propofol/remifentanil provides a faster recovery of consciousness than midazolam/fentanyl but is associated with the need of more vasopressors to maintain stable hemodynamic. Moreover, pharmacokinetic properties of these drugs are often altered during MTH so that standard drug regimens could result in overdosing because of reduced clearance. Neuromonitoring could be helpful to titrate drugs' effects and detect earlier complications (i.e. seizure), while a wake-up test should be avoided during the first 24 hours after CA.
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Minerva anestesiologica · Aug 2014
Percentage hematocrit variation (phevar) index as a quality indicator of patient blood management in cardiac surgery.
Severe hemodilution and perioperative bleeding are determinants of hematocrit (HCT) variations in cardiac surgery patients. These variations may be direct determinants of bad outcomes, and may trigger allogeneic blood product transfusions, which are associated with morbidity and mortality. The present study introduces the Percentage HEmatocrit VARiation (PHEVAR) index as a tool to assess the quality of patient blood management (PBM) and to possibly guide specific interventions. ⋯ The PHEVAR index reflects HCT variations during 7 days of hospital stay in cardiac surgery patients, is associated with mortality and morbidity, and may be used as a quality index for PBM.
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Mechanical ventilation may induce or aggravate lung injury, a phenomenon known as ventilator induced lung injury (VILI). On a macroscopic level, the effects of mechanical stress and strain on lung tissue are well described. Increased tidal volumes may lead to volutrauma, raised airway pressures may cause barotrauma and cyclic collapse and reopening of alveolar units contributes to atelectrauma. ⋯ These cells are involved in sensing and translation of mechanical stimuli into an inflammatory response. This review provides insight into current knowledge of cellular and molecular pathways during the process of pulmonary epithelial mechanosensation and mechanotransduction under different mechanical conditions. Since evidence for specific pathways is generally lacking in some fields of alveolar epithelial mechanotransduction, this article aims at providing reasonable hypothesis for further investigation.
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Minerva anestesiologica · Aug 2014
Comparative StudyHigh-dose fibrinogen versus a clinically recommended dose of fresh frozen plasma for reversal of dilutional coagulopathy in an in vitro model of severe hemodilution.
Volume substitution using colloids and crystalloids dose-dependently induces dilutional coagulopathy. For treatment, fibrinogen concentrate and fresh frozen plasma are options, though the effective dosage of either agent is unclear. The objective of this study was to evaluate, whether high-dose fibrinogen or recommended doses of fresh frozen plasma are equally effective in reversing profound dilutional coagulopathy in vitro. ⋯ High-dose fibrinogen concentrate and clinically recommended doses of fresh frozen plasma are equally effective and can partially restore viscoelastic coagulation assays in profound saline and gelatin dilutions, but only fresh frozen plasma improves conventional coagulation assays. Hydroxyethyl starch-induced disturbance of fibrin polymerization is neither restored by fibrinogen concentrate nor fresh frozen plasma.