Best practice & research. Clinical anaesthesiology
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Tight glycaemic control (TGC) for patients treated in an intensive care unit ICU is associated with an increased risk for hypoglycaemia. Since hypoglycaemia mainly occurs in the sickest patients, no matter whether TGC is applied or not, it might be a marker for severity of illness or a harmful event in itself. Furthermore, it remains a matter of debate whether harmful effects of hypoglycaemia outbalance the clinical benefits of TGC. This review focusses on the clinical manifestations of hypoglycaemia in the critically ill and highlights its potential short- and long-term consequences specifically concerning neurocognitive function.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewUltrasound guided vascular access: efficacy and safety.
Central venous catheterisation and arterial catheterisation are common procedures performed by anaesthetists. Traditionally, the technique of locating surface landmarks and palpation was used to assist in vascular access. ⋯ In the United States and United Kingdom, guidelines have recommended the use of ultrasound guidance to reduce complications and improve success in central venous catheterisation. This article summarises the literature on complication rates, efficacy and safety of ultrasound-guided vascular access procedures and describes a practical method of ultrasound-guided central venous access and arterial catheterisation.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewThe impact of routine trans-oesophageal echocardiography (TOE) in cardiac surgery.
Trans-oesophageal echocardiography (TOE) has profoundly changed cardiac surgery and the role of the cardiac anaesthesiologist. It has been the driving force for a real-time diagnostic and decision-making partnership between cardiac anaesthesiologists and cardiac surgeons that has significantly advanced the safety and effectiveness of modern cardiac surgery. With the information provided by TOE, anaesthesiologists and surgeons may redirect the care of cardiac surgical patients to decrease morbidity and mortality. ⋯ While some colleagues continue to question whether TOE should be used routinely in all cardiac surgical patients, we believe that it is impossible to predict in which cardiac patients TOE will discover vitally important new information. Therefore, we recommend that in the absence of contraindication to oesophageal instrumentation with the probe, TOE should be performed in all cardiac surgical patients. With routine TOE use, TOE will have its greatest benefit.
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Ultrasound is used in anaesthesia for diagnostic and interventional reasons. This article gives the anaesthesiolgoist an overview about the relevant indications for ultrasound in non-cardiac surgical patients. Other chapters will focus in more detail on different aspects of ultrasound use in non-cardiac anaesthesia. ⋯ The use of transcutaneous ultrasound in anaesthesia is mainly interventional: The puncture rate for vascular access e.g. central venous catheterization is higher and the procedure can be performed safer under continuous sonographic guidance. Nerve blockade under direct visualisation of target and accompanying structures has amplified the regional anaesthetic methods. The major nerve blocks are described and discussed.
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The haemodynamic state refers to the integration of myocardial and vascular systems, and involves both left and right hearts, and systolic and diastolic phases. The assessment of the haemodynamic state can be performed with echocardiography, and provides a higher level of diagnosis than conventional pressure- and flow-based monitoring. Whilst hypotension alerts the practitioner about the existence of haemodynamic abnormality, it does not provide sufficient information to identify the cause or the underlying haemodynamic state. ⋯ Patients may have an abnormal haemodynamic state (such a systolic failure), but may not need active treatment if they are haemodynamically stable. However, if treatment is required, it can be directed according to the underlying haemodynamic state. For example, a patient with systolic failure may benefit from inotrope support, whereas an empty state acquires volume infusion and vasodilation requires vasopressor support.