Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2013
ReviewMonitoring respiration: what the clinician needs to know.
A recent large prospective cohort study showed an unexpectedly high in-hospital mortality after major non-cardiac surgery in Europe, as well as a high incidence of postoperative pulmonary complications. The direct effect of postoperative respiratory complications on mortality is still under investigation, for intensive care unit (ICU) and in the perioperative period. ⋯ The aim of this article is to provide an overview of various respiratory monitoring techniques including the role of conventional and most recent methods in the perioperative period and in critically ill patients. The most recent techniques proposed for bedside respiratory monitoring, including lung imaging, are presented and discussed, comparing them to those actually considered as gold standards.
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Best Pract Res Clin Anaesthesiol · Jun 2013
ReviewMonitoring volume and fluid responsiveness: from static to dynamic indicators.
Fluid therapy represents, most of the time, the first-line treatment of circulatory failure in critically ill patients. However, after initial resuscitation, fluid administration can be deleterious in patients with sepsis and/or acute respiratory distress syndrome. In this context, several tests have been developed to predict fluid responsiveness and fluid unresponsiveness to identify patients who can be eligible for fluid therapy (fluid respondents) and those who cannot benefit from volume expansion (fluid non-respondents) and in whom fluid loading can even be deleterious. ⋯ The respiratory variation of arterial pulse pressure and of other surrogates of stroke volume has been used first for this purpose and has received a large amount of evidence. However, such indices suffer from several limitations. In such instances, alternative methods such as passive leg raising, end-expiratory occlusion test or 'mini' fluid challenge have been developed.
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Best Pract Res Clin Anaesthesiol · Jun 2013
ReviewMonitoring the nociception-anti-nociception balance.
At present, short-acting drugs are used in order to achieve the three components of anaesthesia, that is, analgesia, hypnosis and immobility. Assessment of the 'analgesia' component in daily clinical routine is, in contrast to the other components, still based on very unspecific clinical 'end' points such as movement, tearing, tachycardia or hypertension. Individually tailored analgesia, however, should enable to maintain an individual nociceptive-anti-nociceptive balance and better avoid these unwanted responses to surgical stimulation. ⋯ Most of the systems allow a rapid detection of the nociceptive input; nonetheless, the prediction of an autonomic or somatic response has still to be improved. Several studies reported fewer unwanted events, reduced opioid consumption and shorter emergence from anaesthesia, when opioid administration was based upon monitoring of the nociceptive-anti-nociceptive balance. However, research on the mechanisms of pain processing and for better tools to assess the 'analgesia' component has to continue in order to improve our daily practice.
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Best Pract Res Clin Anaesthesiol · Jun 2013
ReviewBrain monitoring revisited: what is it all about?
To easily measure the depth of anaesthesia during routine surgical procedures has always been a goal in anaesthesiology. For decades, scientists have been developing indices to describe and evaluate the depth of anaesthesia. Historically, mean alveolar gas concentration (MAC) values for volatile anaesthetics have been used to target a predefined level of anaesthesia. ⋯ Although monitors measuring the depth of anaesthesia are still not capable of measuring the transition from consciousness to unconsciousness, brain monitoring has proved to help clinicians control the depth of anaesthesia. Clinical trials have shown that the use of brain-monitoring devices can lead to a reduction of intraoperative drug consumption, reduced incidence of postoperative nausea and vomiting, facilitate recovery from anaesthesia compared to routine care and can also lead to a reduction of intraoperative awareness. However a study demonstrating both a reduced intraoperative drug consumption and at the same time a reduction of intraoperative awareness due to the use of brain-monitoring devices has not been published yet.