Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewManaging major obstetric haemorrhage: Pharmacotherapy and transfusion.
Major obstetric haemorrhage is a leading cause of maternal mortality. A prescriptive approach to early recognition and management is critical to improving outcomes. Uterine atony is the primary cause of post-partum haemorrhage. ⋯ Early and empiric use of fixed transfusion red blood cell:plasma:platelet ratios is controversial and may not be justified for all causes of haemorrhage. Cell salvage may be used safely in obstetric haemorrhage. Goal-directed therapy using point-of-care testing (e.g. thromboelastography) has not been well studied but holds promise for individualising resuscitation measures.
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewThe role of ultrasonography in obstetric anesthesia.
Ultrasonography is increasingly being viewed as an everyday tool in obstetric anesthesia. For the administration of spinal or epidural anesthesia, it reduces needle redirection attempts in patients with difficult anatomy. ⋯ Accurate assessment of gastric volume status with ultrasound would be a useful everyday skill if it is adopted into mainstream practice. We provide a summary of current opinions on the role of ultrasound in practice and highlight the potential for its future use in obstetric anesthesia.
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Over the last decade, there has been an increased interest in the use of goal-directed therapy (GDT) in patients undergoing high-risk surgery, and various haemodynamic monitoring tools have been developed to guide perioperative care. Both the complexity of the patient and surgical procedure need to be considered when deciding whether GDT will be beneficial. ⋯ Although global haemodynamic parameters may be optimised with the use of GDT, microvascular impairment can still persist. This review will provide an overview of both haemodynamic optimisation and microvascular assessment in the perioperative period.
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Best Pract Res Clin Anaesthesiol · Dec 2016
ReviewEffect of non-adrenergic vasopressors on macro- and microvascular coupling in distributive shock.
The present review initially describes the rationale for the use of non-adrenergic vasopressors in the treatment of distributive shock and then provides an overview of the individual vasopressin-receptor agonists, namely arginine vasopressin, terlipressin, and selepressin. Following a brief summary of their current use in clinical practice, the present review focuses on the influence of vasopressin-receptor agonists on macro- and microvascular coupling, also referred to as hemodynamic coherence. ⋯ A higher selectivity for the V1a-receptor seems to be beneficial; however, future clinical trials are warranted to verify this assumption. Notably, the optimal treatment regime for non-adrenergic vasopressors with respect to compound, dose, and timing still needs to be defined.
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In case of haemorrhage, a combination of low volume fluid resuscitation and permissive hypotension is used to avoid the adverse effects of early aggressive fluid resuscitation. During this phase, occult microvascular hypoperfusion can possibly develop over time. After controlling the bleeding, it is expected that optimization of macrocirculation will result in an improvement in microcirculation. ⋯ However, haemorrhagic shock, reperfusion, traumatic injury and inflammation can damage microcirculation and thus lead to a loss of haemodynamic coherence. In these cases, a systemic haemodynamic-driven resuscitation would not be effective in restoring microcirculation and tissue oxygenation. A real-time technique enabling microcirculation monitoring can create an opportunity for microcirculatory haemodynamic-driven resuscitation to become the gold standard in the future.