Minerva anestesiologica
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Minerva anestesiologica · Mar 2013
Randomized Controlled TrialMedian effective dose (ED50) of paracetamol and nefopam for postoperative pain: isobolographic analysis of their antinociceptive interaction.
The analgesic efficacy of nefopam and of paracetamol has been shown in the postoperative period after mild- and moderate-pain surgery. The aim of this study was to define the median effective analgesic doses of each drug and of their combination, in order to determine the nature of their interaction. ⋯ The combination of nefopam and paracetamol produces effective analgesia with a synergistic interaction.
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Mortality and morbidity postcardiac surgery with cardiopulmonary bypass (CPB) remain relative stable over the last decades, while the number of patients with increased comorbidity and more complex cardiac disease increases. Nevertheless, end-organ dysfunction and/or failure remain an issue. Multiple perioperative variables, such as non-optimal oxygen delivery, manipulation of the aorta, hyperlactatemia, type of anesthesia, surgical procedure and myocardial protection can be hold responsible for end-organ failure postcardiac surgery. ⋯ Therefore, therapy should focus on controlling perioperative variables that, in combination with the predisposing factors, will further exacerbate organ dysfunction. In order to achieve this, more emphasis should be given to a patient-specific, goal-directed perfusion approach. This review will mainly focus on the impact of perioperative variables.
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Minerva anestesiologica · Mar 2013
ReviewBrain-lung crosstalk in critical care: how protective mechanical ventilation can affect the brain homeostasis.
The maintenance of brain homeostasis against multiple internal and external challenges occurring during the acute phase of acute brain injury may be influenced by critical care management, especially in its respiratory, hemodynamic and metabolic components. The occurrence of acute lung injury represents the most frequent extracranial complication after brain injury and deserves special attention in daily practice as optimal ventilatory strategy for patients with acute brain and lung injury are potentially in conflict. Protecting the lung while protecting the brain is thus a new target in the modern neurointensive care. This article discusses the essentials of brain-lung crosstalk and focuses on how mechanical ventilation may exert an active role in the process of maintaining or treatening brain homeostasis after acute brain injury, highlighting the following points: 1) the role of inflammation as common pathomechanism of both acute lung and brain injury; 2) the recognition of ventilatory induced lung injury as determinant of systemic inflammation affecting distal organs, included the brain; 3) the possible implication of protective mechanical ventilation strategy on the patient with an acute brain injury as an undiscovered area of research in both experimental and clinical settings.
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Acute respiratory distress syndrome (ARDS) is a common entity in critical care medicine and associated with many diagnoses, including trauma and sepsis, which may lead to multiple organ failure and death. Pathophysiologically, increased capillary permeability is the hallmark of ARDS which is characterized by damage of the capillary endothelium and alveolar epithelium in association with impaired fluid removal from the alveolar space and the accumulation of protein-rich fluid inside the alveoli. The clinical management of patients with ARDS is even more difficult, because in the presence of capillary leakage in the lungs, adequate intravascular volume and cardiac preload are required to maintain organ perfusion. ⋯ The transpulmonary thermo-dye dilution technique has been introduced as an instrument to quantify the fluid in the pulmonary capillary bed, i.e., extravascular lung water (EVLW). This technique has shown to be potentially valuable in the management of critically ill patients and has been further developed to be clinically available nowadays as single transpulmonary thermodilution. The following review deals with the measurement of EVLW and its place in the management of critically ill patients with ARDS.