Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jul 2021
ReviewIntraoperative management of thrombectomy for acute ischemic stroke: Do we need general anesthesia?
Since 2015, endovascular thrombectomy has been established as the standard of care for re-establishing cerebral blood flow in patients with acute ischemic stroke. Several retrospective observational studies and prospective clinical trials have investigated two anesthetic techniques for endovascular stroke therapy: general anesthesia (GA) and conscious sedation (CS). ⋯ However, CS techniques are highly variable, and there is currently a lack of consensus on which anesthetic approach is best in all patients. Numerous patient and procedural factors should ultimately guide the decision of whether GA or CS should be used for a particular patient.
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Best Pract Res Clin Anaesthesiol · Jul 2021
ReviewChallenges and pitfalls in anesthesia for electroconvulsive therapy.
Electroconvulsive therapy (ECT) refers to the application of electricity to the patients' scalp to treat psychiatric disorders, most notably, treatment-resistant depression. It is a safe, effective, and evidence-based therapy that is performed with general anesthesia. ⋯ For the anesthesiologist, ECT is associated with the challenges and pitfalls that are related to informed consent, social acceptance of ECT, airway management (especially in COVID-19 patients), and the interaction between ventilation and anesthetics from one viewpoint, and seizure induction and maintenance from another. The exact mode of action of the therapy is as unknown as the optimal choice or combination of anesthetics used.
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Best Pract Res Clin Anaesthesiol · Jul 2021
ReviewMechanical ventilation in neurocritical care setting: A clinical approach.
Neuropatients often require invasive mechanical ventilation (MV). Ideal ventilator settings and respiratory targets in neuro patients are unclear. Current knowledge suggests maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight in neuropatients. ⋯ Additionally, the weaning process from MV is particularly challenging in these patients who cannot control the brain respiratory patterns and protect airways from aspiration. Indeed, extubation failure in neuropatients is very high, while tracheostomy is needed in one-third of the patients. The aim of this manuscript is to review and describe the current management of invasive MV, weaning, and tracheostomy for the main four subpopulations of neuro patients: traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage.
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Best Pract Res Clin Anaesthesiol · Jul 2021
ReviewNoninvasive neuromonitoring in the operating room and its role in the prevention of delirium.
Delirium is a frequent and serious complication after surgery. It has a variable incidence between 20% and 40% with the highest incidence in elderly people undergoing major or cardiac surgery. The development of postoperative delirium (POD) is associated with increased hospital stay lengths, morbidity, the need for home care, and mortality. ⋯ Another noninvasive monitoring technique is NIRS for cerebral tissue hypoxia detection by measuring regional oxygen saturation. The reduction of this parameter does not seem to be associated with the development of POD but with postoperative cognitive dysfunction. There are few studies in the literature and with conflicting results on the use of the pupillometer and transcranial Doppler in predicting the development of postoperative delirium.
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Dexmedetomidine can be used for sedation and analgesia and has been approved for this use by the European Medicines Agency since 2017. It causes an arousable state of sedation, which is beneficial during neurosurgical procedures that require the patient to cooperate with neurological tests (i.e. tumor surgery or implantation of deep brain stimulators). ⋯ The use of dexmedetomidine has also been associated with neuroprotective effects and a decreased incidence of delirium, but studies confirming these effects in the peri-operative (neuro-)surgical setting are lacking. Although dexmedetomidine does not cause respiratory depression, its hemodynamic effects are complex and careful patient selection, choice of dose, and monitoring must be performed.