Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2019
ReviewDiastolic dysfunction - What an anesthesiologist needs to know?
Diastolic dysfunction (DD) is a common condition that is increasingly encountered in patients undergoing both cardiac and noncardiac surgery as the age profile of our patient population increases and the noninvasive diagnosis of DD becomes more accessible. There is a growing body of evidence demonstrating the significance of DD and adverse perioperative outcomes, and thus, it is becoming imperative for anesthesiologists to have an understanding of the pathophysiology, diagnosis, and management of patients with DD. Current guidelines are based on transthoracic echocardiogram (TTE) measurements in patients who are spontaneously breathing and in a euvolemic state and, consequently, not applicable to the perioperative period. In this review article, we discuss the grading of DD as well as introduce a practical approach to the diagnosis and management of patients with DD during the perioperative period.
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Arterial blood pressure monitoring is a major part of the decision-making process for every anesthetic. It is important to recognize the advantages, disadvantages, and limitations of available measurement modalities as well as have some understanding of the engineering principles on which these measurements are based. ⋯ Volume clamp and tonometric technologies are relatively new and allow for continuous noninvasive monitoring of the blood arterial waveform, but their accuracy when compared with oscillometry is not well described, and they have not been widely incorporated into standard practice. Additional research is needed to determine whether continuous noninvasive blood pressure monitors can improve outcomes.
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Best Pract Res Clin Anaesthesiol · Jun 2019
ReviewPerioperative goal-directed therapy - What is the evidence?
Perioperative goal-directed therapy aims at optimizing global hemodynamics during the perioperative period by titrating fluids, vasopressors, and/or inotropes to predefined hemodynamic goals. There is evidence on the benefit of perioperative goal-directed therapy, but its adoption into clinical practice is slow and incomprehensive. ⋯ Perioperative goal-directed therapy protocols need to be started early, should include vasoactive agents in addition to fluids, and should target blood flow related variables. Future promising developments in the field of perioperative goal-directed therapy include personalized hemodynamic management and closed-loop system management.
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Best Pract Res Clin Anaesthesiol · Jun 2019
ReviewPerioperative hemodynamic monitoring: Still a place for cardiac filling pressures?
The clinical usefulness of the so-called "static" cardiac filling pressures - central (CVP) and pulmonary-artery-occlusion-pressure (PAOP) - has come into question for guiding hemodynamic therapy due to their poor ability to predict fluid responsiveness in comparison with other monitoring modalities such as transpulmonary thermodilution-derived volumetric measurements, dynamic variables for assessing fluid responsiveness, and the potential risks associated with pulmonary artery catheterization. This contrasts with observations in multiple patient populations showing a clear association between increased CVP and PAOP levels and poor outcomes, probably due to a reduction in effective perfusion pressure (mean arterial pressure minus CVP) and their role as effectiveness parameters of the cardiovascular system. Furthermore, clinical studies have revealed beneficial effects when interpreting CVP and PAOP dynamically and combining them with flow-related hemodynamic variables. Taking into account the additional information derived from bedside CVP and PAOP pulse curve interpretation, cardiac filling pressures remain an important hemodynamic monitoring tool.
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Best Pract Res Clin Anaesthesiol · Jun 2019
ReviewBest practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring.
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. ⋯ Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.