Articles: postoperative.
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Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in the perioperative period. The authors examined anesthesia closed malpractice claims associated with RD to determine whether patterns of injuries could guide preventative strategies. ⋯ This claims review supports a growing consensus that opioid-related adverse events are multifactorial and potentially preventable with improvements in assessment of sedation level, monitoring of oxygenation and ventilation, and early response and intervention, particularly within the first 24 h postoperatively.
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Cardiac surgery with cardiopulmonary bypass has a major impact on the congenital immune response, in which Toll-like receptors (TLRs) are the first line of defence. Decreased surface expression of TLRs and impaired monocyte responsiveness to TLR ligands occur following surgery. However, the clinical implications of this altered immune response are not clear. ⋯ Clinicaltrials.gov identifier: NCT00356746.
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Hyperkalemia occurs frequently in hospitalized patients and is of particular concern for those who have undergone surgery, with postoperative care provided by clinicians of many disciplines. This review describes the normal physiology and how multiple perioperative factors can disrupt potassium homeostasis and lead to severe elevations in plasma potassium concentration. The pathophysiologic basis of diverse causes of hyperkalemia was used to broadly classify etiologies into those with altered potassium distribution (e.g. increased potassium release from cells or other transcellular shifts), reduced urinary excretion (e.g. reduced sodium delivery, volume depletion, and hypoaldosteronism), or an exogenous potassium load (e.g. blood transfusions). ⋯ Certain acute conditions and chronic co-morbidities present particular risk. These include chronic kidney disease, diabetes mellitus, many outpatient preoperative medications (e.g. beta blockers, salt substitutes), and inpatient agents (e.g. succinylcholine, hyperosmolar volume expanders). Clinicians need to be aware of these pathophysiologic mechanisms for developing perioperative hyperkalemia as many of the risks can be minimized or avoided.
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Observational Study
Pleth variability index and fluid responsiveness of hemodynamically stable patients after cardiothoracic surgery.
Fluid responsiveness is a measure of preload dependence and is defined as an increase in cardiac output due to volume expansion. Recent publications have suggested that variation in amplitude of the pulse oximetry waveform may be predictive of fluid responsiveness. The pleth variability index (PVI) was developed as a noninvasive bedside measurement of this variation in the pulse oximetry waveform. ⋯ Among postoperative cardiac surgery patients, PVI is not reliable for predicting fluid responsiveness as measured by pulmonary artery catheter thermodilution, regardless of ventilatory status.