Best practice & research. Clinical anaesthesiology
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Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15-20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. ⋯ The suggested perioperative ventilation management includes (a) awake and/or facilitated endotracheal intubation by using a video-laryngoscope; (b) tidal volume of 6-10 ml kg(-1) ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding intrinsic positive end-expiratory pressure (PEEPi); and (c) a recruitment manoeuvre (35-55 cmH2O for 6 s) followed by the application of an end-expiratory pressure (PEEP) of 10 cmH2O. The recruitment manoeuvre should always be performed only when a volemic and haemodynamic stabilisation is reached after induction of anaesthesia. In the postoperative period, beach chair position, aggressive physiotherapy, noninvasive respiratory support and short-term recovery in intermediate critical care units with care of fluid management and pain may be useful to reduce pulmonary complications.
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Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewRole of spontaneous and assisted ventilation during general anaesthesia.
Spontaneous ventilation during general anaesthesia has been shown to favour atelectasis formation and decreased functional residual capacity. Therefore, general anaesthesia is commonly associated with endotracheal intubation and mechanical ventilation. Laryngeal lesions, residual curarisation, haemodynamics impairment, but most importantly, situation of cannot ventilate-cannot intubate may occur. ⋯ Spontaneous ventilation assisted by PSV with laryngeal mask may avoid all the complications of endotracheal intubation and mechanical ventilation. Therefore, PSV should be a valid alternative for all patients having general anaesthesia with the exception of some contraindication. A close monitoring of tidal volume and minute ventilation is also needed.
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Best Pract Res Clin Anaesthesiol · Mar 2010
ReviewPlatelet transfusions: the science behind safety, risks and appropriate applications.
Platelets are active metabolising cells that are evolved for the tasks of haemostasis, inflammatory reactions and wound healing. When platelet products are stored in the blood bank a complex series of changes occur, leading to partial activation, up-regulation of inflammatory mediators, cellular morphology changes, loss of cell membrane lipids and micro-particle formation, as well as apoptosis. The resultant coagulation transfusion product has a number of potential expected side effects including fever, alloimmunisation, sepsis, thrombosis and transfusion-related acute lung injury. ⋯ However, outcome data (controversial) have shown in some populations that platelet transfusions are associated with worse patient outcomes. Such associations may be due to the biologic changes that have occurred during storage, lack of HLA matching as well as other causes or it could be a mismatch of the platelet products to patient's needs (over-use). Platelets are administered in the surgical arena often due to 'clinical judgement', which errs on the side of, perhaps, too frequent use.
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As the life expectancy of our Western population progressively increases, so does the prevalence of cardiovascular disease and thus the use of antithrombotic drugs. The use of central neuraxial anaesthesia techniques in patients treated with these drugs is a major clinical problem as the presence of an impaired coagulation has been found to be the most important risk factor contributing to the formation of a spinal haematoma. The growing number of case reports of spinal haematoma has led many national societies of anaesthetists to come up with guidelines. This article presents an overview of current guidelines on the use of regional anaesthetic techniques in patients treated with various anticoagulants and also describes a possible strategy to deal with new antithrombotic drugs that have recently been introduced in some countries or will be shortly in others.
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Interruption or maintenance of anti-platelet agents (APAs) during surgical or invasive procedures is associated with an increase in cardiovascular or haemorrhagic complications, respectively. The pharmacology and indications of aspirin, clopidogrel and prasugrel are summarised. The utility and risks of interruption, the optimal delay between stent implantation and surgery, the appropriate window of preoperative interruption, the potential usefulness of bridging, the safest delay between the end of surgery and resumption of APA are detailed in this review. Some non-evidence-based suggestions are given to help the physicians in their daily clinical practice.