Best practice & research. Clinical anaesthesiology
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The ability to reduce brain injury before, during or after an ischaemic injury, irrespective of the cause, remains an exciting prospect. In this article, we will discuss some of the current research behind cerebral protection, which will include the use of anaesthetic agents, as well as therapies targeted specifically at the complex cascades following brain injury.
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Best Pract Res Clin Anaesthesiol · Mar 2008
ReviewCardiovascular protection by anti-inflammatory statin therapy.
Statins are widely used in the prevention of atheromatous disease and its complications. While their lipid lowering effects are very important, there is increasing emphasis on the other effects of statins described as pleiotropic. These include atheromatous plaque stabilisation generally ascribed to their anti-inflammatory properties. ⋯ The majority of the studies have shown benefits of statin therapy. The reason for these reported benefits is the anti-inflammatory properties of statins in the face of the known release of such mediators during major surgery, leading to plaque disruption and major adverse cardiac events. To date there are too few randomised controlled studies to recommend the prophylactic administration of statins preoperatively, yet the cohort studies are suggestive of benefits.
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With recent advances in surgical and anaesthetic management, clinical medicine has responded to societal expectations and the number of operations in patients with a high-risk of perioperative liver failure has increased over the last decades. This review will outline important pathophysiological alterations common in patients with pre-existing liver impairment and thus highlight the anaesthetic challenge to minimise perioperative liver insults. It will focus on the intraoperative balancing act to reduce blood loss while maintaining adequate liver perfusion, the various anaesthetic agents used and their specific effects on hepatic function, perfusion and toxicity. Furthermore, it will discuss advances in pharmacological and ischaemic preconditioning and summarise the results of recent clinical trials.
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Perioperative cardiac complications pose the greatest risk to the estimated 100 million people undergoing non-cardiac surgery each year. Most of these complications are related to underlying pre-existing coronary artery disease (CAD). For over 40 years researchers have been studying perioperative cardiac risk and how best to estimate it. ⋯ Risk stratification has taken on an important role in clinical decision-making, helping physicians decide in which patients additional medical therapies, such as coronary revascularization or perioperative beta-blockers, are necessary. Meta-analysis has found a significant improvement in the positive predictive value (PPV) for perioperative cardiac outcome with stress testing over that with clinical risk score alone. However, evidence is mounting that with the use of perioperative beta-blockers, the majority of intermediate and high-risk patients can safely undergo even major vascular surgery without further cardiac testing.
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Best Pract Res Clin Anaesthesiol · Mar 2008
ReviewBeta blockers and alpha2 agonists for cardioprotection.
Perioperative beta blockade or the use of alpha2 agonists remains a contentious and controversial area of perioperative medicine. Although there is no question that the liberal use of beta blockers (or alpha2 agonists) to prevent or reduce overt signs of sympathetic overactivity, particularly at known periods of stress (e.g. induction, incision, emergence, etc) is an important and routine part of the management of high risk patients, there remains considerable controversy in the literature regarding the efficacy of either short or long-term regimens on cardiac morbidity or long-term outcomes, particularly in those patients not previously receiving medication for known coronary artery disease or hypertension. The role of strict heart rate control (and its safety with regards to hypotension and possibly congestive heart failure) versus intermittent fixed dosing of beta blockers is particularly contentious. We consider the latest literature on this topic and identify areas of agreement and contention and present the latest recommendations of the American Heart Association/American College of Cardiology Perioperative Guidelines Group.