Minerva anestesiologica
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Intraoperative brain mapping has the goal of aiding with maximal surgical resection of brain tumors while minimizing functional sequelae. Retrospective randomized studies on large populations have shown that this technique can optimize the surgical approach while reducing postoperative morbidity. During direct electrical stimulation of the language areas adjacent to the tumor, the patient should be collaborative and be able to speak to participate in language testing. ⋯ Since awake craniotomy carries both benefits and potential risks, the following factors are crucial in the management of patients: 1) careful selection of the patients and 2) communication between the anesthesiological and surgical teams. To date, there remains no consensus about the optimal anesthesiological regimen to use. Only prospective, multicentre randomized studies focused on evaluating the role of different anesthesiological techniques on intraoperative monitoring, postoperative deficits, and intraoperative complications can answer the question of which anesthesiological approach should be chosen when intraoperative brain mapping is requested.
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Patients with chronic airflow obstruction and difficulty in weaning from mechanical ventilation are at increased risk for intubation-associated complications and mortality because of prolonged invasive mechanical ventilation. Non-invasive ventilation (NIV) may avert most of the pathophysiologic mechanisms associated with weaning failure in these patients. Several randomised controlled trials have shown that the use of NIV in order to advance extubation in difficult patients can result in reduced periods of endotracheal intubation, complication rates and survival. ⋯ In addition, the patients were hemodynamically stable, with a normal level of consciousness, no fever and a preserved cough reflex. The use of NIV in the management of respiratory failure after extubation did not show clinical benefits, although clinical trials included a small proportion of chronic respiratory patients. In contrast, NIV immediately after extubation is effective in avoiding respiratory failure after extubation in patients at risk for this complication, particularly those with chronic respiratory disorders and hypercapnic respiratory failure.
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Minerva anestesiologica · Jun 2008
ReviewQuality and quantity of volume replacement in trauma patients.
An epidemiologic evaluation of trauma-related deaths in trauma centers reveals that the majority of patients die within 6 hours from exsanguination, whereas secondary brain injuries predominate between 6 and 24 hours. Late deaths remain attributable to sepsis and pulmonary embolism,1-3 while early deaths are due in part to multiple bleeding injuries or to a set of complex and untreatable injuries, mainly of the liver and pelvis. Before trauma systems existed, these patients died at the scene of the trauma, whereas since the establishment of the trauma system, they die in emergency or operating rooms. ⋯ Moreover, increases in blood pressure before surgical hemostasis have been shown to disrupt clotting and increase bleeding, a fact that has been confirmed by a number of animal and human studies on uncontrolled hemorrhage. Furthermore, oxygen must be delivered to vital organs (brain, heart) to prevent death during hemorrhage. In summary, several constraints account for the differences in fluid use, timing of infusions, and determinations of whether to administer fluids at all.
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Muscle wasting and paralysis are common complications in Intensive Care Unit (ICU) patients, where critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), alone or in combination (CIP/CIM), are the commonest causes. CIP is an acute axonal sensory-motor polyneuropathy usually suspected in ICU patients who, after a period of days or weeks, cannot be weaned from the ventilator despite the absence of pulmonary or cardiac causes of respiratory failure, or because they suffer from various degrees of limb weakness. CIM is an acute primary myopathy with a continuum of myopathic findings, from myopathies with pure functional impairment and normal histology to myopathies with atrophy and necrosis. ⋯ Recent data indicate that CIM has a better prognosis than CIP, and differential diagnosis is therefore important to predict long term outcome in ICU patients. Bioenergetic failure is thought to be a relevant pathophysiological mechanism explaining both CIP/CIM and multi-organ failure. Indeed, CIP/CIM itself should be considered as the failure of the peripheral nervous-muscular system.
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Ischemic heart disease is the major cause of morbidity and mortality in the Western world. With the advancing age of the surgical population, anesthesiologists increasingly have to treat patients with known or suspected ischemic heart disease in the perioperative period. Over the years various strategies have been developed to prevent myocardial ischemia in the perioperative period and/or to minimize the extent of myocardial damage after perioperative ischemia. This review summarizes the current knowledge on the subject and focuses on the more recent data concerning perioperative cardioprotection by anesthetic agents.