Best practice & research. Clinical anaesthesiology
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Fluid therapy is a core concept in the management of perioperative and critically ill patients for maintenance of intravascular volume and organ perfusion. Recent evidence regarding the vascular barrier and its role in terms of vascular leakage has led to a new concept for fluid administration. ⋯ In daily practice, the assessment of individual thresholds in order to optimize cardiac preload and avoid hypovolaemia or deleterious fluid overload remains a challenge. Liberal versus restrictive fluid management has been challenged by recent evidence, and the ideal approach appears to be goal-directed fluid therapy.
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Best Pract Res Clin Anaesthesiol · Sep 2014
ReviewRole of the glycocalyx in fluid management: Small things matter.
Intravenous fluid therapy and perception of volume effects are often misunderstood. The pharmacokinetical difference between colloids and crystalloids depends on the condition of the vascular permeability barrier. Its functioning is still largely based on Starling's principle from 1896, realising that transport of fluid to and from the interstitial space follows the balance between opposing oncotic and hydrostatic pressures. ⋯ While crystalloids can freely pass through the glycocalyx, colloids are held back in the vasculature by this structure. This is reflected by a markedly higher intravascular persistence of isooncotic colloids (80-100%) versus crystalloids (around 20%), at least as long as the glycocalyx is intact. Protecting this structure in surgical practice means limiting the surgical trauma and avoiding intravascular hypervolemia.
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Best Pract Res Clin Anaesthesiol · Jun 2014
ReviewEvolution of the transversus abdominis plane block and its role in postoperative analgesia.
Since it was first described by Rafi in 2001, the transversus abdominis plane (TAP) block can be best described as a peripheral nerve block to the anterior abdominal wall (T6 to L1). The TAP block is specifically a local anesthetic injection into the fascial plane superficial to the transversus abdominis muscle and deep to the internal oblique muscle. The TAP block has been a subject of controversy with regard to utility, to indications, and more fundamentally, how best to place the block and its precise mechanism of action. ⋯ The TAP block affords excellent analgesia for abdominal procedures. In summary, the TAP block affords effective analgesia with opioid sparing effects, technical simplicity, and long duration of action. Some disadvantages include the need for bilateral block for midline incisions and absence of effectiveness for visceral pain.
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Despite an appreciation for many unwanted physiological effects from inadequate pain postoperative relief, moderate to severe postoperative pain remains commonplace. Though treatment options have evolved in recent years, including improvement in medications, multimodal regimens, and regional anesthetic techniques, including ultrasound and continuous catheters, outcomes data indicate that many of these strategies are associated with varying degrees of morbidity and mortality. This review focuses on the importance of effective postoperative analgesia and both short- and long-term effects associated with inadequate management. A careful literature review of emphasizing treatment options and potential pathogenesis associated with these strategies is emphasized in this review.