Minerva anestesiologica
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Minerva anestesiologica · May 2009
ReviewTargeting transpulmonary pressure to prevent ventilator induced lung injury.
Acute respiratory distress syndrome (ARDS) and ventilator induced lung injury (VILI) continue to challenge clinicians who care for the critically ill. Current research in ARDS has focused on ventilator strategies to improve the outcome for these patients. In this review, we emphasize the limitations of managing ventilators based on airway pressures alone. ⋯ This review suggests that perturbations in chest wall compliance and transpulmonary pressure may explain the lack of efficacy observed in recent clinical trials of ventilator management. We present a method for estimating pleural and transpulmonary pressures from esophageal manometry. Quantifying these variables and individualizing ventilator management based on individual patient physiology may be useful to intensive care clinicians who treat patients with ARDS.
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More and more frequently anaesthetists must be able to provide complete, integrated anaesthetic care outside the traditional environment of the operating room. Providing non-operating room anaesthesia (NORA) has gained widespread popularity. Both the number and the complexity of these therapeutic and diagnostic procedures is increasing. ⋯ From what is available in the literature paediatric patients carry a high risk of complications; monitored anaesthesia care is associated with more complications and substandard care is often present. Despite these potential risks, the mortality and morbidity related to NORA is infrequently studied and poorly described. Most authors agree that improvements in monitoring are essential to decrease the complication rate.
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Maintenance of a patent and prevention of aspiration are essential for the management of the trauma patient, that requires experienced physicians in airway control techniques. Difficulties of the airway control in the trauma setting are increased by the vital failures, the risk of aspiration, the potential cervical spine injury, the combative patient, and the obvious risk of difficult tracheal intubation related to specific injury related to the trauma. ⋯ Different techniques to control the airway in trauma patients are presented: improvement of the laryngoscopic vision, lighted stylet tracheal intubation, retrograde technique for orotracheal intubation, the laryngeal mask and the intubating laryngeal mask airways, the combitube and cricothyroidotomy. Management of the airway in trauma patients requires regular training in these techniques and the knowledge of complementary techniques allowing tracheal intubation or oxygenation to overcome difficult intubation and to prevent major complications as hypoxemia and aspiration.
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This review describes the incidence, risk factors, and long-term consequences of cognitive dysfunction after cardiovascular surgery. Postoperative cognitive dysfunction (POCD) is increasingly being recognized as an important complication, especially in the elderly. A highly sensitive neuropsychological test battery must be used to detect POCD and a well-matched control group is very useful for the analysis and interpretation of the test ⋯ POCD seems to have important long-term consequences regarding self-assessed quality of life, survival, and labor market attachment.
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Minerva anestesiologica · May 2009
ReviewPropofol infusion syndrome: update of clinical manifestation and pathophysiology.
Propofol infusion syndrome (PRIS) is defined as acute bradycardia progressing to asystole combined with lipemic plasma, fatty liver enlargement, metabolic acidosis with negative base excess >10 mmol l(-1), rhabdomyolysis or myoglobinuria associated with propofol infusion. The purpose of this review was to provide a new update of reported case reports and to describe recent retrospective studies and animal research relevant for the pathophysiology and clinical presentation of PRIS. New case reports of PRIS have confirmed previously identified risk factors, and have also further revealed the incidence of PRIS in patients previously not estimated to be at risk for this syndrome. ⋯ PRIS has to be kept in mind if propofol is used for anesthesia or sedation. Recommendations for the limitation of propofol use have to be adhered to. Early warning signs must prompt immediate cessation of propofol infusion and adequate treatment.