Best practice & research. Clinical anaesthesiology
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Rapid atrial arrhythmias affect close to one million elderly Americans who undergo cardiac or non-cardiac operations annually and have been associated with prolonged hospital stays. In contrast, bradyarrhythmias or ventricular arrhythmias severe enough to require treatment occur in less than 1% of patients who undergo all types of surgery, including cardiac. ⋯ New approaches directed at prophylaxis and acute therapy of atrial arrhythmias are discussed, as are recommendations to prevent thromboembolic events. Practice and research agenda are proposed.
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies of neuroprotection for intracranial aneurysms.
Neuroprotection for patients with intracranial aneurysms encompasses the preservation of brain cells endangered by a limited blood and oxygen supply due to aneurysm rupture, clipping or coiling, as well as vasospasm. A large variety of prophylactic and therapeutic neuroprotective strategies have been proposed, but success in human disease is quite limited. ⋯ New concepts are ischaemic preconditioning, growth factors, and gene therapy. Each strategy is rated on underlying evidence, and research agendas are mentioned.
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Despite advances in our understanding of the neurobiology of nociception, postoperative pain continues to be undertreated. There are many modalities that may provide effective postoperative analgesia, including systemic (e.g. opioids, non-steroidal anti-inflammatory agents) and regional analgesic options. The particular modality or modalities utilized for a particular patient will depend on the risk-benefit profile and patient preferences. Ideally, analgesic options should be incorporated into a multimodal approach to facilitate patient recovery after surgery.
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Sepsis and septic shock are the leading causes of death in intensive care units in developed countries despite recent advances in critical care medicine. Sepsis is the systemic inflammatory response to infection frequently associated with hypoperfusion followed by tissue injury and organ failure. ⋯ In addition, the application of small doses hydrocortisone to patients with refractory septic shock and the treatment of patients with septic multiple organ failure with activated protein C are two adjunctive therapeutic strategies. Promising new experimental treatment options are interference with MIF, HMGB1, C5a or TREM-1 signal transduction pathways and an inhibition of apoptosis, which may further improve the prognosis of septic patients in the future.
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Best Pract Res Clin Anaesthesiol · Sep 2004
ReviewInflammatory response to cardiac surgery: cardiopulmonary bypass versus non-cardiopulmonary bypass surgery.
Cardiac surgery has been routinely performed using cardiopulmonary bypass (CPB) ever since its clinical introduction during the 1950s. CPB is, however, associated with an intense inflammatory response because of conversion to laminar flow, blood contact with the artificial bypass surface, cold cardiac ischaemia and hypothermia. The inflammatory reaction can intensify to a systemic inflammatory response syndrome (SIRS) associated with serious morbidity and mortality. ⋯ The development of cardiac immobilization techniques allowing complete revascularization has caused a renaissance of coronary artery bypass grafting surgery on the beating heart (OPCAB). This strategy avoids all inflammation caused by CPB and reduces the pro-inflammatory stimulus to sternotomy and the revascularization procedure itself. This review summarises the pathophysiological features of the inflammatory response to CPB, revisits therapeutic anti-inflammatory strategies designed to suppress CPB-induced inflammation and balances the clinical evidence available comparing off-pump and on-pump revascularization.