Best practice & research. Clinical anaesthesiology
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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.
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Best Pract Res Clin Anaesthesiol · Mar 2008
ReviewPharmacogenomics and end-organ susceptibility to injury in the perioperative period.
Genomic medicine has provided new mechanistic understanding for many complex diseases over the last 5-10 years. More recently genomic approaches have been applied to the perioperative paradigm, facilitating identification of patients at high risk for adverse events, as well as those who will respond better/worse to specific pharmacologic therapies. ⋯ Precise predictors of each adverse event are being elucidated so that corrective therapeutics can be instituted to improve outcomes in high-risk patients. While the field of perioperative genomics could be considered in its infancy, such approaches are the wave of the future.
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Preserving donor organs in optimal condition is a prerequisite for successful transplantation. The donor organ is subjected to a multitude of stresses. ⋯ As progressively more is known about the underlying pathophysiological mechanisms, focused and efficient therapeutic interventions can be developed. We will review current organ protection techniques and look at possible future strategies to further improve the final donor organ quality.