Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies in the high-risk cardiac patient undergoing non-cardiac surgery.
The risk of perioperative myocardial infarction or cardiac death in patients undergoing non-cardiac surgery may be estimated by clinical risk factor analysis and by myocardial stress testing. While stress testing modalities accurately delineate reversible myocardial ischaemia, their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone. ⋯ Administration of beta-blockers and alpha2-adrenergic agonists to high-risk patients reduces surgical morbidity and mortality, and the benefits observed with beta-blockers may extend long after the operative period. In high-risk patients undergoing major surgery, pulmonary artery catheter-guided haemodynamic optimization has not been associated with better outcomes, whereas use of regional anesthetic techniques decreases the incidence of postoperative pulmonary, but not cardiac, complications.
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewRenal protection strategies in the perioperative period.
The development of acute renal failure (ARF) in the perioperative period continues to be a vexing condition associated with high morbidity and mortality rates which have been unchanged for several decades. In this article I briefly review recent research categorizing pathogenesis of ARF and mechanisms of recovery. ⋯ The main focus of the article is on assessing clinical and experimental interventions to prevent ARF. Unfortunately, existing pharmacological and other interventions show a rather limited efficacy in preventing ARF.
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Transfusion of allogeneic red blood cells (RBCs), fresh frozen plasma (FFP) and platelets is associated with risks, and outcome studies comparing liberal and restrictive transfusion regimens are lacking in surgical patients. Therefore, guidelines have been established. ⋯ FFP transfusions are recommended for urgent reversal of anticoagulation, known coagulation factor deficiencies, microvascular bleeding in the presence of elevated (> 1.5 times normal) prothrombin time (PT) or partial thromboplastin time (PTT) and microvascular bleeding after the replacement of more than one blood volume when PT or PTT cannot be obtained. Platelet transfusions are recommended prior to major operations in patients with platelet counts < 50,000/microl, intraoperatively with microvascular bleeding at platelet counts < 50,000/microl and in the range of 50,000-100,0000/microl following cardiopulmonary bypass and in patients undergoing surgery where already minimal bleeding may cause major damage such as in neurosurgery.
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies in the patient with compromised respiratory function.
Respiratory diseases are commonly divided into restrictive or obstructive lung diseases. For anaesthesiological considerations restrictive lung diseases appear as a static condition with minimal short-term development. Overall, restrictive lung diseases don't lead to acute exacerbations due to the choice of anaesthetic techniques or the choice of anaesthesia-specific agents. ⋯ The use of regional anaesthesia alone or in combination with general anaesthesia can help to avoid airway irritation and even leads to reduced postoperative complications. Prophylactic anti-obstructive treatment, volatile anaesthetics, propofol, opioids, and an adequate choice of muscle relaxants minimize the anaesthetic risk when general anaesthesia is required. If intraoperative bronchospasm occurs, despite all precautions, deepening of anaesthesia, repeated administration of beta2-adrenergic agents and parasympatholytics, and a single systemic dose of corticosteroids are the main treatment options.
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Airway management is a critical part of anaesthesia practice. Management includes mask ventilation, laryngoscopy, endotracheal intubation and extubation of the patient. ⋯ The American Association of Anesthesiologists (ASA) developed and recently revised guidelines for the management of the difficult airway. These guidelines focus on strategies for intubation as well as alternative airway techniques that can be used when a patient with a difficult airway is encountered.