MedWorm.com provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest items from the 'Best Practice and Research. Clinical Anaesthesiology' source. Sun, 29 Jan 2012 07:38:26 +0100 http://www.medworm.com/index.php?rid=5421444&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000930%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421444 Sat, 19 Nov 2011 00:52:00 +0100 5421444 http://www.medworm.com/index.php?rid=5421443&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000620%2Fabstract%3Frss%3Dyes The history of ethics in clinical research parallels the history of abuse of human beings. The Nuremberg Code, Declaration of Helsinki, and the Belmont Report laid the foundations for modern research ethics. In the United States, the OHRP and the FDA provide guidelines for the ethical conduct of research. Investigators should be familiar with regulations concerning informed consent, doing research in vulnerable populations, and protection of privacy. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421443 Sat, 19 Nov 2011 00:52:00 +0100 5421443 http://www.medworm.com/index.php?rid=5421442&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000619%2Fabstract%3Frss%3Dyes Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in ‘systems-based practice’ and ‘practice-based learning and improvement’ as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality an... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421442 Sat, 19 Nov 2011 00:52:00 +0100 5421442 http://www.medworm.com/index.php?rid=5421441&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000826%2Fabstract%3Frss%3Dyes This article summarises the basics of genetic inheritance, the human genome and modern sequencing methods, as well as genetic variation and how this knowledge may be applied to patient care and research in the perioperative setting. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421441 Sat, 19 Nov 2011 00:52:00 +0100 5421441 http://www.medworm.com/index.php?rid=5421440&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000632%2Fabstract%3Frss%3Dyes The goal of comparative effectiveness research (CER) is to improve effectiveness, efficacy and efficiency in health care. While CER seems to present a major opportunity to introduce accountability into health care by identifying and promoting best practices in medicine, many issues surrounding CER remain poorly understood by clinicians and researchers, including what study designs are most appropriate for such research and what analytic tools are most helpful. The goal of this review is therefore to provide background and definitions of what constitutes CER and to discuss the various study designs and their strengths and weaknesses in achieving the stated goals of CER, while relating them to examples relevant to perioperative research. We provide a brief outline of the types of analytic me... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421440 Sat, 19 Nov 2011 00:52:00 +0100 5421440 http://www.medworm.com/index.php?rid=5421439&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000644%2Fabstract%3Frss%3Dyes Meta-analysis uses numerical tools to pool data and to estimate a summary effect size for the comparison of two interventions from a set of randomised controlled trials identified in a systematic review. An effect size is a single number that expresses the difference in outcome from the interventions. The most commonly used effect sizes for dichotomous outcomes, for example, mortality, are the odds ratio and the relative risk. The results of a meta-analysis are usually presented in a complex figure, known as a forest plot, which shows both the individual studies and the summary statistics. Sensitivity analyses are performed to clarify the effect of the experimental design bias on the effect size. Clinical and statistical heterogeneity of the included studies are explored by the additional ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421439 Sat, 19 Nov 2011 00:52:00 +0100 5421439 http://www.medworm.com/index.php?rid=5421438&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000668%2Fabstract%3Frss%3Dyes For more than 30 years in the United States, we have been lamenting the fate of the clinician-scientist in anaesthesiology. In the past 5 years, attention to the issues has escalated and a number of new training pathways have emerged. This chapter summarizes programs which have innovative curricula, analyzes current research needs and discusses the limited studies in regards to best practices for research training in graduate medical education. It also proposes further development of residency research curricula through the application of basic educational concepts and explores funding issues and resources that remain relevant to all faculty and departments training the residents. We hope the ideas proposed here will promote the academic caliber of our profession; however, much more data a... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421438 Sat, 19 Nov 2011 00:52:00 +0100 5421438 http://www.medworm.com/index.php?rid=5421437&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000656%2Fabstract%3Frss%3Dyes We present a review illustrating by example how in silico modelling has been applied to a number of cardio-respiratory problems in states of health and disease, the purpose of which is to give the reader a sense of the complexity and assumptions which underlie this diverse and underappreciated research strategy, as well as an introduction to a research strategy that will likely continue to grow in importance. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421437 Sat, 19 Nov 2011 00:52:00 +0100 5421437 http://www.medworm.com/index.php?rid=5421436&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000814%2Fabstract%3Frss%3Dyes While the delivery of anaesthesia care is largely a safe process and adverse events are infrequent, they can have devastating consequences for patients and providers when they occur. Given concerns about the role of anaesthesia care in shaping long-term outcomes traditionally considered outside the scope of anaesthesiology, new avenues for perioperative research are being explored at a rapid rate by anaesthesia researchers. We propose that new research methodologies such as perioperative effectiveness research could shed useful insight into processes leading to improved clinical care if applied appropriately and optimally. In this article, we outline the basic concepts of perioperative outcomes and effectiveness research. We highlight many sources of data, both clinical and non-clinical, a... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421436 Sat, 19 Nov 2011 00:52:00 +0100 5421436 http://www.medworm.com/index.php?rid=5421435&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000607%2Fabstract%3Frss%3Dyes This article reviews the terminology, current practice and current research in simulation. The use of simulation in assessment of the clinical performance of devices, people and systems will then be discussed and some current work in these areas presented. Finally, medical simulation will be discussed within the paradigm of translational research. Early examples of this ‘tool-bench to bedside’ model will be presented as possible prototypes for future work directed towards patient safety. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421435 Sat, 19 Nov 2011 00:52:00 +0100 5421435 http://www.medworm.com/index.php?rid=5421434&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000838%2Fabstract%3Frss%3Dyes “Study the past if you would define the future”Confucius (551 BC– 479 BC) The prospective, randomized trial serves as the “gold standard” for the generation of medical evidence that guides patient care. The modern clinical trial has become so fundamental to the practice of medicine it is impossible to imagine the adoption of a new drug, therapy, or technique without supportive data. We could go on to argue that, more than any other advance, the clinical trial and modern clinical research is the single greatest medical advance of the past 100 years. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421434 Sat, 19 Nov 2011 00:52:00 +0100 5421434 http://www.medworm.com/index.php?rid=5421433&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000899%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5421433 Sat, 19 Nov 2011 00:52:00 +0100 5421433 http://www.medworm.com/index.php?rid=5236659&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000760%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236659 Thu, 01 Sep 2011 04:00:00 +0100 5236659 http://www.medworm.com/index.php?rid=5236658&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000565%2Fabstract%3Frss%3Dyes The association between physical fitness and outcome following major surgery is well described – less fit patients having a higher incidence of perioperative morbidity and mortality. This has led to the idea of physical training (exercise training) as a perioperative intervention with the aim of improving postoperative outcome. Studies have started to explore both preoperative training (prehabilitation) and postoperative training (rehabilitation). We have reviewed the current literature regarding the use of prehabilitation and rehabilitation in relation to major surgery in elderly patients. We have focussed particularly on randomised controlled trials, systematic reviews and meta-analyses. There is currently a paucity of high-quality clinical trials in this area, and the evidence base in... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236658 Thu, 01 Sep 2011 04:00:00 +0100 5236658 http://www.medworm.com/index.php?rid=5236657&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000589%2Fabstract%3Frss%3Dyes It is ethically and legally important, when providing care to our patients, to respect their autonomy and dignity, to act in their best interests and avoid doing harm. Advance care planning is essential to achieving this by giving patients the opportunity to tell us what they would want us to do if they became seriously unwell and could no longer communicate their wishes. Whereas earlier attempts at advance care planning focussed on the completion of forms, the more recent, successful focus has been on the patient-centred discussion, involving family, appointment of substitute decision makers and identification of what the patient would see as an acceptable outcome from any proposed treatment. Advance care planning is successful in caring for the elderly, including in the perioperative set... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236657 Thu, 01 Sep 2011 04:00:00 +0100 5236657 http://www.medworm.com/index.php?rid=5236656&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000498%2Fabstract%3Frss%3Dyes Average life expectancy has increased over the past century resulting in a shift in world population demographics. There are more elderly people alive now than throughout all of human history. The burden of comorbid disease and dependency rises with age and has been shown to independently predict need for hospitalization, institutionalization and mortality. Accordingly, there are more elderly persons living longer in more tenuous states of health. The relative proportion of patients admitted to hospital and intensive care who are elderly is considerable and recent data have suggested an increasing trend. There is likely significant selection bias amongst elderly patients triaged for access to finite critical care services. In fact, data have shown that elderly patients often receive less i... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236656 Thu, 01 Sep 2011 04:00:00 +0100 5236656 http://www.medworm.com/index.php?rid=5236655&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000577%2Fabstract%3Frss%3Dyes This article reviews the current literature on the value and practical applications of cardiopulmonary exercise testing (CPET) as a tool to evaluate risk and thereby improve the management of the elderly patient undergoing major surgery. There is a consistent association between CPET-derived variables and outcome following major surgery. Furthermore, CPET-derived variables have utility in perioperative risk prediction and identification of patients at high risk of adverse outcome following major surgery. This optimal predictor appears to differ between various surgery types and the incremental benefit of combining CPET with alternative methods of perioperative risk prediction remains poorly defined. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236655 Thu, 01 Sep 2011 04:00:00 +0100 5236655 http://www.medworm.com/index.php?rid=5236654&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961100053X%2Fabstract%3Frss%3Dyes Inflammation is an adaptive response to surgery. When the pro-inflammatory responses are unregulated and become over reactive, systemic inflammatory response syndrome may occur. Postoperative systemic inflammation is more common than is generally acknowledged and is observed in about 10–15% of elderly patients undergoing major surgery. Although the vast majority of systemic inflammation is related to infections, other important predisposing risk factors, such as extent of trauma and haemorrhage, should not be overlooked.Increased awareness, modification of risk factors and early recognition are the key elements in the management of systemic inflammation. Prompt resuscitation aiming to correct hypotension, hypovolaemia and tissue hypoxia may improve outcome.Future large prospective observ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236654 Thu, 01 Sep 2011 04:00:00 +0100 5236654 http://www.medworm.com/index.php?rid=5236653&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000528%2Fabstract%3Frss%3Dyes Acute kidney injury (AKI) in the elderly patient is a common iatrogenic complication of major surgery that impacts morbidity, mortality and resource use. Several renal functional and structural changes have been described, including a substantially decreased nephron mass. Loss of renal function defines AKI and is classified by the RIFLE (R: renal risk, I: injury, F: failure, L: Loss and E: End-stage renal disease) criteria; however, it frequently occurs many hours to several days after the injury to the kidney. Therefore, novel biomarkers indicating tubulo-interstitial damage are needed for early AKI diagnosis. The limitations of serum creatinine are much more pronounced in the elderly, including its dependence on muscle mass and the presence of multiple drug use and co-morbidities. Althou... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236653 Thu, 01 Sep 2011 04:00:00 +0100 5236653 http://www.medworm.com/index.php?rid=5236652&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000590%2Fabstract%3Frss%3Dyes Albumin has been the focus of literally thousands of articles since its first use in the clinical setting during World War II. Despite being at the centre of several clinical controversies, many questions still remain regarding the use and abuse of albumin. The major physiologic functions include maintaining colloid osmotic pressure, binding and transport of metabolically active molecules, serving as an antioxidant, use as a surrogate marker of nutritional status and predictor of outcome in elective surgical populations, having an anti-thrombotic influence on platelets, aiding in acid–base balance and having a protective influence on capillary membrane integrity. Albumin will continue to be widely used in clinical medicine despite many of the drawbacks. It now appears the benefits in the... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236652 Thu, 01 Sep 2011 04:00:00 +0100 5236652 http://www.medworm.com/index.php?rid=5236651&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000462%2Fabstract%3Frss%3Dyes Postoperative cognitive dysfunction (POCD) was originally thought to be associated with cardiac surgery, but has since been associated with non-cardiac surgery and even sedation for non-invasive procedures such as coronary angiography. The focus of POCD has thus shifted from the type of surgery or anaesthetic to patient susceptibility. The realisation that cognitive impairment, such as mild cognitive impairment (MCI – the prodrome for Alzheimer’s disease (AD)), may already exist in many elderly patients who incidentally present for surgery beckons anaesthesia to align cognitive research with that of AD in order to draw valid parallels between the two disciplines. Long-term studies are required to understand if POCD is merely a transient phenomenon, or if it is the harbinger of long-ter... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236651 Thu, 01 Sep 2011 04:00:00 +0100 5236651 http://www.medworm.com/index.php?rid=5236650&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000516%2Fabstract%3Frss%3Dyes The average age of the world’s population is increasing rapidly, with those over 80 years of age the fastest growing subsection of older persons. Consequently, a higher proportion of those presenting for surgery in the future will be older, including greater numbers aged over 100 years. Management of postoperative pain in these patients can be complicated by factors such as age and disease-related changes in physiology, and disease-drug and drug–drug interactions. There are also variations in pain perception and ways in which pain should be assessed, including in patients with cognitive impairment. Alterations in pharmacokinetics and pharmacodynamics may influence drugs and techniques used for pain relief. The evidence-base for postoperative pain management in the older population rema... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236650 Thu, 01 Sep 2011 04:00:00 +0100 5236650 http://www.medworm.com/index.php?rid=5236649&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000504%2Fabstract%3Frss%3Dyes In developed countries, a growing proportion of patients presenting for anesthesia and surgery are elderly. Despite this, and the fact that aging is known to be associated with alterations in drug pharmacokinetics and dynamics, there is little detailed information about the impact of aging on the pharmacology of commonly used anesthetic agents.In this review, we discuss existing current knowledge on the physiological changes that occur with age and the way these changes affect the pharmacokinetics and dynamics of anesthetic agents. Also, an overview of up-to-date PK-PD modeling concepts and their usefulness and limitations in modern anesthesiologic practice with respect to the elderly population is given. Finally, newer agents such as sugammadex, remifentanyl, ropivacaine and desflurane ar... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236649 Thu, 01 Sep 2011 04:00:00 +0100 5236649 http://www.medworm.com/index.php?rid=5236648&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000553%2Fabstract%3Frss%3Dyes Normal ageing of the cardiopulmonary system overlaps with the development of cardiovascular disease. It is characterised by changes which decrease cardiovascular reserve through senescent changes in myocardial function and volumes. These changes are compounded by co-existing cardiovascular disease, multisystem co-morbidities and polypharmacy. Indices of vascular ageing permit risk prediction in the perioperative setting. The investigation of these changes using arterio-ventricular coupling has highlighted preload sensitivity and beta-adrenergic and baroreflex insensitivity as the cardinal features which influence cardiovascular performance. Anaesthesia interferes with each of the components and poses substantial challenges. Comprehensive preoperative evaluation and optimisation assist in c... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236648 Thu, 01 Sep 2011 04:00:00 +0100 5236648 http://www.medworm.com/index.php?rid=5236647&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000486%2Fabstract%3Frss%3Dyes Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. There is emerging work on quantifying frailty as a further risk factor for perioperative complication and mortality as well as need for higher level of care after discharge from hospital. Important postoperative complications include sepsis and kidney injury. Preventing, detecting and managing complications and mortality is the greatest challenge facing those caring for surgical pat... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236647 Thu, 01 Sep 2011 04:00:00 +0100 5236647 http://www.medworm.com/index.php?rid=5236646&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000474%2Fabstract%3Frss%3Dyes Populations globally are ageing, in part due to dramatic increases in life expectancies, forcing a reconsideration of what constitutes being “elderly” and “old.” The proportion of older adults living with disability may be decreasing, yet older individuals are living with a significant burden of chronic disease, geriatric impairments in cognition, vision and hearing and reduced physiological reserve (frailty). Caring for a growing number of medically complex individuals has implications for medical workforce size and composition, health programmes and expenditure. Future responses to an ageing population will require further innovation in health-care delivery models, and increasing representation of older adults in clinical trials. (Source: Best Practice and Research. Clinical Anae... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236646 Thu, 01 Sep 2011 04:00:00 +0100 5236646 http://www.medworm.com/index.php?rid=5236645&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000541%2Fabstract%3Frss%3Dyes As anaesthesiologists, most of us are encountering an increasing number of older patients. The definition of ‘old’ will often depend on the life expectancy of a patient’s community. Older patients are undergoing increasingly sophisticated surgical and interventional procedures. While age itself is an important prognostic factor, co-morbidity is also very important for risk assessment in the perioperative period. The American Society of Anesthesiologists (ASA) physical status appears to be a remarkably robust single measure of co-morbidity. Frequently, age and co-morbidity have a greater association with complications and mortality than the surgical procedure, a point often missed by our surgical colleagues. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236645 Thu, 01 Sep 2011 04:00:00 +0100 5236645 http://www.medworm.com/index.php?rid=5236644&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000723%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=5236644 Thu, 01 Sep 2011 04:00:00 +0100 5236644 http://www.medworm.com/index.php?rid=4805357&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000437%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805357 Wed, 11 May 2011 14:48:11 +0100 4805357 http://www.medworm.com/index.php?rid=4805356&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000309%2Fabstract%3Frss%3Dyes For years now, the German Society of Anaesthesiology and Intensive Care Medicine and the Professional Association of German Anaesthesiologists have been actively involved in efforts to improve patient safety. To this end, a whole range of activities have been initiated in recent years and, since February 2011, collected together on our home page ‘PATSI’ (www.patientensicherheit-ains.de). Further, the implementation of syringe labelling (ISO 26825) with additional information on drugs frequently used in intensive care was carried out. Under the item Helsinki Declaration, all decisions and recommendations so far worked out by our speciality have, in structured form, been assigned to individual points and saved as PDF files. This has made it possible for every anaesthesiological departmen... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805356 Wed, 11 May 2011 14:48:11 +0100 4805356 http://www.medworm.com/index.php?rid=4805355&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000085%2Fabstract%3Frss%3Dyes In June 2010, the European Board of Anaesthesiology (EBA) of the European Union of Medical Specialists (UEMS) and the European Society of Anaesthesiology (ESA) signed the Helsinki Declaration for Patient Safety in Anaesthesiology at the Euroanaesthesia meeting in Helsinki. The document had been jointly prepared by these two principal anaesthesiology organisations in Europe who pledged to improve the safety of patients being cared for by anaesthesiologists working in the medical fields of perioperative care, intensive care medicine, emergency medicine and pain medicine. The declaration stated their current heads of agreement on patient safety and listed a number of principle requirements as thought necessary for anaesthesiologists, anaesthesiology departments and institutions to introduce t... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805355 Wed, 11 May 2011 14:48:10 +0100 4805355 http://www.medworm.com/index.php?rid=4805354&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000267%2Fabstract%3Frss%3Dyes The American Society of Anesthesiologists (ASA) Closed Claims database was started in 1985 to study anaesthesia injuries to improve patient safety, now containing 8954 claims with 5230 claims since 1990. Over the decades, claims for surgical anaesthesia decreased, while claims for acute and chronic pain management increased. In the 2000s, chronic pain management involved 18%, acute pain management 9% and obstetrical anaesthesia formed 8% of claims. Surgical anaesthesia claims with monitored anaesthesia care (MAC) increased in the 2000s to 10% of claims, while regional anaesthesia involved 19%. The most common complications were death (26%), nerve injury (22%) and permanent brain damage (9%). The most common damaging events due to anaesthesia in claims were regional-block-related (20%), res... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805354 Wed, 11 May 2011 14:48:10 +0100 4805354 http://www.medworm.com/index.php?rid=4805353&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000322%2Fabstract%3Frss%3Dyes Patient Safety is not a side-effect of good patient care by skilled clinicians. Patient safety is a subject on its own, which was traditionally not taught to medical personnel. This must and will dramatically change in the future. The 2010 Helsinki Declaration for Patient Safety in Anaesthesiology states accordingly “Education has a key role to play in improving patient safety, and we fully support the development, dissemination and delivery of patient safety training”. Patient safety training is a multidisciplinary topic and enterprise, which requires us to cooperate with safety experts from different fields (e.g. psychologists, educators, human factor experts). Anaesthesiology has been a model for the patient safety movement and its European organisations like ESA and EBA have pionee... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805353 Wed, 11 May 2011 14:48:10 +0100 4805353 http://www.medworm.com/index.php?rid=4805352&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000103%2Fabstract%3Frss%3Dyes This article explores the importance of human factors training for safe care of patients and the role of simulation. Based on the available literature, the need to integrate this type of training to increase awareness of the importance of human factors and to change attitudes appears obvious. A combination of different training methods appears to be useful. Simulation-based training appears to be favourable, although the number of studies demonstrating the impact of training is limited. It is important to develop training programmes for individual teams, based on the knowledge of challenges and deficiencies, and to monitor behavioural change. Several methods, including patient safety data, interviews, observational studies and simulations, can be used to specify learning objectives. The ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805352 Wed, 11 May 2011 14:48:10 +0100 4805352 http://www.medworm.com/index.php?rid=4805351&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000073%2Fabstract%3Frss%3Dyes This article starts from a social science viewpoint and reviews the concepts and measurement of safety culture and climate in their original industrial settings and in health care. Typical items measured and generic characteristics of a positive safety culture are described. The role of personality, professional group membership and anaesthesiology-specific knowledge and expertise in shaping notions of risk and safety and safety behaviour are discussed. The difficulties of changing human behaviour are outlined, and the pivotal role which anaesthesiologists can play in promoting a positive safety culture, both individually and within their teams and organisations, is highlighted. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805351 Wed, 11 May 2011 14:48:09 +0100 4805351 http://www.medworm.com/index.php?rid=4805350&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000243%2Fabstract%3Frss%3Dyes This article examines the non-technical skills approach to enhancing operational safety, with particular reference to anaesthesia. Training and assessing the non-technical skills of staff in safety-critical occupations is accepted by high-risk industries, most notably aviation, but has only recently been adopted in health care. These authors explain the background to the concept of non-technical skills that was first adopted in relation to the behaviours of airline pilots and could enhance or jeopardise safety. Then, this article considers one particular non-technical skills framework for doctors, the Anaesthetists’ Non-Technical Skills (ANTS) taxonomy and behaviour-rating tool. This was the first non-technical skills framework specifically designed for anaesthetists, and the authors exp... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805350 Wed, 11 May 2011 14:48:09 +0100 4805350 http://www.medworm.com/index.php?rid=4805349&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000061%2Fabstract%3Frss%3Dyes Incident reporting can be a powerful tool to detect weaknesses in the complex system of anaesthesiology. Having its roots in aviation, incident reporting today is used in a variety of medical disciplines at the local and even on the national level. Strength of incident reporting is the potential for learning from rare and potentially dangerous events. To properly set up an incident reporting system requires certain conditions to support and motivate reporters. It, furthermore, needs a sound definition or a model of a critical incident as well as a strategy to analyse the reported events. In Europe, a number of countries already run a national reporting system in anaesthesiology with large collections of critical events. These national systems, furthermore, distribute hazard warnings to spr... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805349 Wed, 11 May 2011 14:48:09 +0100 4805349 http://www.medworm.com/index.php?rid=4805348&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961100005X%2Fabstract%3Frss%3Dyes A key role in anaesthetic practice is gathering and assimilating information from a variety of sources to construct and maintain an accurate mental model of what is happening to the patient, a model that will influence subsequent decisions made by the anaesthetist on the patient’s behalf, as part of a larger team. Effective performance of this role requires a set of mental functions that place great demands upon the physiology and psychology of anaesthetists, functions that are vulnerable to a wide range of factors including those affecting team performance and those affecting the anaesthetist specifically. The number of tasks, their complexity, the physical and mental demands of the job, the underlying health and well-being of the anaesthetist and the environment and context within whic... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805348 Wed, 11 May 2011 14:48:09 +0100 4805348 http://www.medworm.com/index.php?rid=4805347&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000255%2Fabstract%3Frss%3Dyes In the recent patient safety literature, there is an increasing agreement that effective patient handover is critical to patient safety by ensuring appropriate coordination among health-care providers and continuity of care. It has repeatedly been pointed out that a lack of formal training and formal systems for patient handover impede the good practice necessary to maintain high standards of clinical care. Thus, patient handover has been defined a research priority for patient safety, and research in this field is increasing rapidly. In reviewing the current state of research and improvement, we identified key areas for future research. Despite the growing evidence at the descriptive level, future research will have to take a more systematic approach to establish valid measures of handove... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805347 Wed, 11 May 2011 14:48:09 +0100 4805347 http://www.medworm.com/index.php?rid=4805346&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000115%2Fabstract%3Frss%3Dyes Critical incidents may have serious psychological and health-related impact on patients, their families and the health-care providers involved. Exploring the needs of health-care providers and patients and their families in the aftermath of a critical incident, this article highlights a disconnect between the widely acknowledged ethical obligation for open disclosure and current practice, reviews the available evidence on effective disclosure and barriers to open disclosure and provides an overview of what health-care organisations can do to alleviate the impact of critical incidents on staff, patients and their families. The most critical elements are: (1) effective support systems for clinicians, (2) guidelines on critical incident management including immediate measures, disclosure stan... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805346 Wed, 11 May 2011 14:48:08 +0100 4805346 http://www.medworm.com/index.php?rid=4805345&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000097%2Fabstract%3Frss%3Dyes Following the overwhelming evidence of adverse events in hospital practice, the World Health Organization (WHO)'s World Alliance for Patient Safety has launched the ‘Safe Surgery Saves Lives’ campaign, which has developed a surgical safety checklist aimed to improve patient safety. The implementation of this checklist has met with mixed reactions in different institutions. Many countries have still not adopted its use. In this article, a brief review is presented regarding the role of the WHO checklist, barriers to its implementation and strategies for successful adoption. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805345 Wed, 11 May 2011 14:48:08 +0100 4805345 http://www.medworm.com/index.php?rid=4805344&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000280%2Fabstract%3Frss%3Dyes The administration of medications is central to anaesthetists’ care of patients. Errors are inevitable in any human endeavour, but should be distinguished from violations. The incidence of medication errors in anaesthesia has been estimated as 1 per 13 000 administrations, excluding errors in recording. Adverse medication events follow a proportion of these errors. Labelling is a key element of medication safety. There is a long-standing need for improvements in the labelling of ampoules and vials. An international standard exists for labelling syringes used during anaesthesia (ISO 26825). Australia has recently released national recommendations for labelling lines and injectable medications that complement this and other relevant standards. The provision of at least some medications in... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805344 Wed, 11 May 2011 14:48:08 +0100 4805344 http://www.medworm.com/index.php?rid=4805343&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000334%2Fabstract%3Frss%3Dyes This article examines a domain of research on system safety – the High Reliability Organization (HRO) paradigm. HROs operate in hazardous conditions, but have fewer than their fair share of adverse events. HROs are committed to safety at the highest level and adopt a special approach to its pursuit. The attributes and operating dynamics of the best HROs provide a template on which to better understand how safe and reliable performance can be achieved under trying conditions, and this may be useful to researchers and caregivers who seek to improve safety and reliability in health care. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805343 Wed, 11 May 2011 14:48:08 +0100 4805343 http://www.medworm.com/index.php?rid=4805342&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000279%2Fabstract%3Frss%3Dyes Based on results recorded of perioperative mortality, anaesthetic care is often cited as a model for its improvements with regard to patient safety. However, anaesthesia-related morbidity represents a major burden for patients as yet in spite of major progresses in this field since the early 1980s. More than 1 out of 10 patients will have an intraoperative incident and 1 out of 1000 will have an injury such as a dental damage, an accidental dural perforation, a peripheral nerve damage or major pain. Poor preoperative patient evaluation and postoperative care often contribute to complications. Human error and inadequate teamwork are frequently identified as major causes of failures. To further improve anaesthetic care, high-risk technical procedures should be performed after systematic trai... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805342 Wed, 11 May 2011 14:48:07 +0100 4805342 http://www.medworm.com/index.php?rid=4805341&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000292%2Fabstract%3Frss%3Dyes There is an increasing demand for systems for measuring the quality of our medical work.In this article, we present a suggestion for how one can attempt to do this in a department of anaesthesia. It would be desirable to measure real clinical outcomes such as morbidity and mortality. However, such events are rare and not suitable for routine recording of work quality. Instead, we propose a system based on indicators of process quality and surrogate clinical outcomes. Surrogates may provide useful information if chosen carefully and checked for validity. We further suggest that such indicators be recorded routinely on every anaesthesia chart. The rate of the indicator can then be followed over time with the use of statistical process control methods. The foundation for such a system for mea... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805341 Wed, 11 May 2011 14:48:07 +0100 4805341 http://www.medworm.com/index.php?rid=4805340&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000310%2Fabstract%3Frss%3Dyes The issue of patient safety has always been top priority on anaesthesiologists’ agenda, and it is widely acknowledged that anaesthesiology is the leading medical speciality in addressing issues of patient safety. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805340 Wed, 11 May 2011 14:48:07 +0100 4805340 http://www.medworm.com/index.php?rid=4805339&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000395%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4805339 Wed, 11 May 2011 14:48:07 +0100 4805339 http://www.medworm.com/index.php?rid=4593636&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000218%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593636 Tue, 01 Mar 2011 00:00:00 +0100 4593636 http://www.medworm.com/index.php?rid=4593635&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000935%2Fabstract%3Frss%3Dyes Nearly 20% of all patients admitted to an intensive-care unit are obese. Their excess weight puts them at risk for several problems and complications during their intensive-care unit stay. Especially, pulmonary problems need particular attention, and comprehensive knowledge of the specific pathophysiologic changes of the respiratory system is important. Lung protective ventilation strategies, supplemented by lung-recruiting manoeuvres, may be feasible in critically ill obese patients with lung injury. Careful positioning of the obese is essential to optimise ventilation and facilitate weaning from mechanical ventilation. Optimal hypocaloric nutrition with a high proportion of proteins is advised to control hyperglycaemia. Because mortality in obese patients is similar to or lower than in n... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593635 Tue, 01 Mar 2011 00:00:00 +0100 4593635 http://www.medworm.com/index.php?rid=4593634&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000960%2Fabstract%3Frss%3Dyes Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The ‘ramped’ upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. Intra-operative hypoxaemia can be treated with the combin... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593634 Tue, 01 Mar 2011 00:00:00 +0100 4593634 http://www.medworm.com/index.php?rid=4593633&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000911%2Fabstract%3Frss%3Dyes In the obese patient, the goal of postoperative pain management is provision of comfort, early mobilisation and improved respiratory function without causing inadequate sedation and respiratory compromise.The pathophysiology of obesity, typical co-morbidities and the high prevalence of obstructive sleep apnoea (OSA) amongst obese patients make safe analgesic management difficult. In particular, pain control after bariatric surgery is a major challenge. Although several reviews covering anaesthesia and analgesia for obese patients are published, there is mainly expert opinion and a paucity of evidence-based recommendations. Advice on general management includes multimodal analgesic therapy, preference for regional techniques, avoidance of sedatives, non-invasive ventilation with supplementa... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593633 Tue, 01 Mar 2011 00:00:00 +0100 4593633 http://www.medworm.com/index.php?rid=4593632&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000959%2Fabstract%3Frss%3Dyes Obesity is associated with a number of anaesthetic-related risks. Regional anaesthesia offers many potential advantages for the obese surgical patient. Advantages include a reduction in systemic opioid requirements and their associated side effects, and possible avoidance of general anaesthesia in select circumstances, with a lower rate of complications. Historically, performing regional anaesthesia procedures in the obese has presented challenges due to difficulty in identifying surface landmarks and availability of appropriate equipment. Ultrasound guidance may aid the regional anaesthesia practitioner with direct visualisation of underlying anatomic structures and real-time needle direction. Further research is needed to determine optimal regional anaesthesia techniques, local anaesthet... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593632 Tue, 01 Mar 2011 00:00:00 +0100 4593632 http://www.medworm.com/index.php?rid=4593631&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000947%2Fabstract%3Frss%3Dyes The incidence of childhood obesity ranges today from approximately 8% to 17%, and is an increasing issue in developed and developing countries. This disease will become increasingly significant in paediatric anaesthesia. Obese children not only have anaesthesia-relevant co-existing diseases, that are, asthma and hypertension, but also have a higher incidence of anaesthesia-related complication. This review covers current definition and some epidemiology of childhood obesity. It summarises potential co-morbidities and provides details for preoperative evaluation, anaesthetic management and prevention of perioperative complications. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593631 Tue, 01 Mar 2011 00:00:00 +0100 4593631 http://www.medworm.com/index.php?rid=4593630&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961000090X%2Fabstract%3Frss%3Dyes Obesity is a worldwide epidemic with increasing importance in both industrialised and developing countries. Anaesthesiologists will be increasingly challenged by the care for morbidly and super-obese patients. Prerequisites for an optimal perioperative care are a suitable and adapted environment both on the ward and in the operating theatre, the timely and comprehensive preoperative evaluation focussed on co-morbidities, such as diabetes, coronary artery disease and obstructive sleep apnoea syndrome and appropriate equipment for positioning, anaesthesia and surgery. To deliver an adequate standard of care, anaesthesiologists must consider the pharmacokinetic characteristics and pathophysiological sequelae of obesity. Careful preoxygenation, special positioning, adequate monitoring and adap... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593630 Tue, 01 Mar 2011 00:00:00 +0100 4593630 http://www.medworm.com/index.php?rid=4593629&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000923%2Fabstract%3Frss%3Dyes The steady rise in obesity observed in the recent years, coupled with its associated co-morbidities, suggests that clinicians will encounter obese patients with increasing frequency in their daily practice. Unfortunately, obese subjects are often excluded from clinical trials during the drug development process. Hence, the appropriate dose for obese patients is most often inferred from normal-weight subjects. Pharmacokinetic and pharmacodynamic variations induced by obesity are numerous and with profound clinical implications, particularly in anaesthesia and intensive care. This review provides a pragmatic approach to the pharmacokinetic considerations that should guide drug administration. We hereby offer a systematic approach to dosing scalars, followed by an analysis of the factors affe... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593629 Tue, 01 Mar 2011 00:00:00 +0100 4593629 http://www.medworm.com/index.php?rid=4593628&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000024%2Fabstract%3Frss%3Dyes The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese – specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. Medical treatments of obesity include primary prevention, dietary intervention, increased physical activity, behavior modification, and pharmacotherapy. Surgical treatment for obesity is based on the extensive neural-hormonal effects of weight loss surgery on metabolism, and as such is better termed Metabolic Surgery. Surgery is not limited to the procedure itself, it also necessitates t... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593628 Tue, 01 Mar 2011 00:00:00 +0100 4593628 http://www.medworm.com/index.php?rid=4593627&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000036%2Fabstract%3Frss%3Dyes Positive energy imbalance Energy imbalance leads to obesity. A majority of the US population is overweight, a third obese and nearly 5% morbidly obese. In the developing world, this problem continues to evolve in an rapid manner, creating challenges for already burdened health systems. In many instances, the environment contributes to the problem. Factors ranging from the availability of calorie-dense foods, decreased time spent in physical activities, technologically assisted household chores to time spent watching television, all have some contribution to the problem. Much more needs to be done to control this obesity epidemic, both from a public health as well as a communal-expense perspective. Forced misuse of economic resources and wasted potential lives should drive a better coordina... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593627 Tue, 01 Mar 2011 00:00:00 +0100 4593627 http://www.medworm.com/index.php?rid=4593626&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000048%2Fabstract%3Frss%3Dyes Overweight and obesity have evolved as a global pandemic, which challenges the health-care systems not only in the industrialised but also in the developing countries. In the US and most European countries, approximately 50% of the population is overweight and obese, respectively. The lifestyle predominant in the Western countries favours a positive energy balance, which ultimately may produce subjects classified as ‘super-super obese’(body mass index (BMI) > 60 kg m−2) or ‘mega-obese’ (BMI > 70 kg m−2). Even more alarming is the fact that the incidence of obesity and morbid obesity is dramatically increasing among children and adolescents. Taken together, obesity, with its related co-morbidities and sequelae, has gained significant impact on health-care policy and reso... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593626 Tue, 01 Mar 2011 00:00:00 +0100 4593626 http://www.medworm.com/index.php?rid=4593625&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689611000176%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4593625 Tue, 01 Mar 2011 00:00:00 +0100 4593625 http://www.medworm.com/index.php?rid=4214578&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000868%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214578 Wed, 01 Dec 2010 00:00:00 +0100 4214578 http://www.medworm.com/index.php?rid=4214577&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000716%2Fabstract%3Frss%3Dyes This article reviews the preclinical and clinical work on EPO for the indications neuroprotection/neuroregeneration and cognition, and hopefully will stimulate new endeavours promoting development of EPO for the treatment of human brain diseases. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214577 Wed, 01 Dec 2010 00:00:00 +0100 4214577 http://www.medworm.com/index.php?rid=4214576&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000686%2Fabstract%3Frss%3Dyes Occlusion of a brain vessel leads to a critical reduction in cerebral perfusion and, within minutes, to ischemic infarction with a central infarct core of irreversibly damaged brain tissue and a more or less large area of hypoperfused but still vital brain tissue (the ischemic penumbra), which can be salvaged by rapid restoration of blood flow. Therefore, the underlying rationale for the introduction and application of thrombolytic agents is the lysis of an obliterating thrombus and thus reestablishment of cerebral blood flow by cerebrovascular recanalization with subsequent reperfusion. After introduction of thrombolytic therapy for the treatment of acute myocardial infarction in the early 1990s, major trials for the evaluation of this new therapeutic approach to ischemic stroke were ini... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214576 Wed, 01 Dec 2010 00:00:00 +0100 4214576 http://www.medworm.com/index.php?rid=4214575&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000753%2Fabstract%3Frss%3Dyes Introduction: Multiple sclerosis (MS) is the most common chronic inflammatory disease of the central nervous system which is characterized by inflammatory demyelination and neurodegeneration. Neurological symptoms include sensory disturbances, optic neuritis, limb weakness, ataxia, bladder dysfunction, cognitive deficits and fatigue.Pathophysiology: The inflammation process with MS is promoted by several inflammatory cytokines produced by the immune cells themselves and local resident cells like activated microglia. Consecutive damaging pathways involve the transmigration of activated B lymphocytes and plasma cells, which synthesize antibodies against the myelin sheath, boost the immune attack, and result in ultimate loss of myelin. Likewise, activated macrophages and microglia are present... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214575 Wed, 01 Dec 2010 00:00:00 +0100 4214575 http://www.medworm.com/index.php?rid=4214574&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000741%2Fabstract%3Frss%3Dyes The endpoint of all cerebral injuries like stroke, global cerebral ischemia during cardiac arrest, cardiac, vascular, or brain surgery or head trauma is the inadequate supply of the brain with oxygen and glucose, which triggers a characteristic pathophysiologic cascade leading to neuronal death. Many methods and agents have been investigated to produce neuroprotection from cerebral ischemia along this cascade (e.g., hypothermia, anaesthetics, free radical scavengers, excitatory amino acid antagonists, calcium channel blockers, ionic pump modulators, growth factors, heparinization, antineutrophil/platelet factors, steroids, and gene products). However, essentially none of the pharmacological approaches was identified as useful in humans though most agents have been successfully tested in an... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214574 Wed, 01 Dec 2010 00:00:00 +0100 4214574 http://www.medworm.com/index.php?rid=4214573&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000704%2Fabstract%3Frss%3Dyes Stroke is a leading cause of morbidity and mortality, with perioperative stroke being an important complication in the practice of anaesthesia. Unfortunately, pharmacological treatment options are very limited and often not applicable in the perioperative period. The notion of applying a subtoxic stimulus prior to an otherwise lethal event is termed preconditioning. The main focus of the article is on describing the different concepts of preconditioning, including remote ischaemic preconditioning and anaesthetic preconditioning, as well as postconditioning and summarizing the most recent discoveries in this exciting field. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214573 Wed, 01 Dec 2010 00:00:00 +0100 4214573 http://www.medworm.com/index.php?rid=4214572&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000698%2Fabstract%3Frss%3Dyes Ischemic stroke comprises a complex cascade of pathophysiological mediators among which reactive oxygen species (ROS) play a pivotal role. Although oxidative stress as one major component contributing to ischemia–reperfusion injury has been thoroughly studied before, efficient treatment options for patients with ischemic stroke have so far not been transferred into clinical practice. In this review, the authors first describe some of the fundamental pathophysiological mechanisms that are involved in ROS generation after cerebral ischemia. Thereafter, antioxidant defense mechanisms and pharmacological manipulation of oxidative stress in various models of experimental cerebral ischemia are reviewed. The authors finally comment on recent clinical studies analyzing the effect of an antioxida... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214572 Wed, 01 Dec 2010 00:00:00 +0100 4214572 http://www.medworm.com/index.php?rid=4214571&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000674%2Fabstract%3Frss%3Dyes This article reviews the current knowledge on cascades that are activated after ischaemic and traumatic brain injury and that lead to progression of tissue damage. Main attention will be on pathophysiological events initiated after ischaemic stroke including excitotoxicity, oxidative/nitrosative stress, peri-infarct depolarizations, apoptosis and inflammation. Additionally, specific pathophysiological aspects after traumatic brain injury will be discussed along with their similarities and differences to ischaemic brain injury. This article provides prerequisites for understanding the therapeutic strategies for stroke and trauma patients which are addressed in other articles of this issue. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214571 Wed, 01 Dec 2010 00:00:00 +0100 4214571 http://www.medworm.com/index.php?rid=4214570&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000728%2Fabstract%3Frss%3Dyes Acquired brain injury, including both Ischaemic stroke (IS) and Traumatic Brain injury (TBI), is one of the most common causes of disability and death in adults. Yet there are vast differences in our knowledge of their epidemiology. While the incidence, case-fatality and risk factors for stroke are well established, work needs to continue particularly in low-income countries, where these data remain sparse; and in relation to specific stroke subtypes such as IS. Similar data regarding the epidemiology of TBI are generally lacking. The majority of TBI incidence studies have focussed on hospital-based samples and there are no established criteria from which to design high quality epidemiological studies. The need to establish such criteria separate from those already available for stroke is ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214570 Wed, 01 Dec 2010 00:00:00 +0100 4214570 http://www.medworm.com/index.php?rid=4214569&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961000073X%2Fabstract%3Frss%3Dyes For decades pharmacological interventions have been tested for their neuroprotective characteristics because of their potential to interrupt, or slow the sequence of injurious biochemical and molecular events ultimately resulting in irreversible neuronal death. Unfortunately, clinical trials on neuroprotection failed to translate the experimental evidence. At this stage of disappointment and reservation as to future research related to neuroprotection the issue deserves a critical appraisal and motivated approach to future work that needs to be done. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214569 Wed, 01 Dec 2010 00:00:00 +0100 4214569 http://www.medworm.com/index.php?rid=4214568&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000820%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=4214568 Wed, 01 Dec 2010 00:00:00 +0100 4214568 http://www.medworm.com/index.php?rid=3955570&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000649%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955570 Tue, 31 Aug 2010 23:00:00 +0100 3955570 http://www.medworm.com/index.php?rid=3955569&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000339%2Fabstract%3Frss%3Dyes Neonates are both capable of experiencing pain and memory formation, albeit implicit memory. During surgical procedures, insufficient ablation of the stress response and possible implicit memory formation of intra-operative events might result in adverse early and long-term outcomes. Neonates deserve the same respect as adult patients. It is thus the responsibility of the anaesthetist to provide sufficient anaesthesia for neonates undergoing surgery. A critical approach in weighing the risks and benefits of exposing a neonate to anaesthesia is prudent, and truly elective surgery should be delayed. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955569 Tue, 31 Aug 2010 23:00:00 +0100 3955569 http://www.medworm.com/index.php?rid=3955568&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000285%2Fabstract%3Frss%3Dyes techniques are evolving. More sophisticated methods of monitoring have emerged and current practices have been challenged. It is recognised that most newborns will require only gentle assistance to facilitate the transition from intrauterine life. The routine use of suction and oxygen supplementation is no longer recommended and the effectiveness of current methods of delivering ventilatory support has been questioned. The importance of effective use of masks and optimising tidal ventilation rather than pressure generation is emphasised. Newer oximetry technologies and the routine use of capnography may facilitate clinical assessment even during active resuscitation. Methods of warming infants have become increasingly effective and the use of servo-control is emphasised to prevent overhea... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955568 Tue, 31 Aug 2010 23:00:00 +0100 3955568 http://www.medworm.com/index.php?rid=3955567&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000327%2Fabstract%3Frss%3Dyes This article provides the clinician with an introductory understanding of the approval process of pharmaceuticals in the United States by USFDA. Models of clinical trial design are noted. Examples of anaesthetic and non-anaesthetic agents and their development and use are discussed as either ‘labelled’ or ‘off-label’ indications. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955567 Tue, 31 Aug 2010 23:00:00 +0100 3955567 http://www.medworm.com/index.php?rid=3955566&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000303%2Fabstract%3Frss%3Dyes This article summarises the currently available preclinical and clinical information regarding the impact of anaesthetics, sedatives, opioids, pain and stress, inflammation, hypoxia–ischaemia, co-morbidities and genetic predisposition on brain structure and long-term neurological function. Moreover, this article outlines the putative mechanisms of anaesthetic neurotoxicity, and the phenomenon’s implications for clinical practice in this rapidly emerging field. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955566 Tue, 31 Aug 2010 23:00:00 +0100 3955566 http://www.medworm.com/index.php?rid=3955565&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000364%2Fabstract%3Frss%3Dyes Neonatal anaesthesia dosing needs to be based on physiological characteristics of the newborn, pharmacokinetic/pharmacodynamic considerations and the adverse effects profile. Disease processes and treatments in this group are distinct from adults. Absorption, distribution and clearance are altered because of immaturity of enzyme, anatomical or physiological systems resulting in extensive variability of drug disposition in neonates. This is further compounded by pharmacogenomic influences. Population and physiological-based pharmacokinetic modelling have improved understanding of maturation and subsequent dose approximation. Postmenstrual age is a reasonable measure for maturation, although postnatal age may also have an impact. The neonatal response to drugs is also altered. Although neuro... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955565 Tue, 31 Aug 2010 23:00:00 +0100 3955565 http://www.medworm.com/index.php?rid=3955564&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000340%2Fabstract%3Frss%3Dyes Up to recently, inserting venous or arterial ‘lines’ in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors’ experience. Live illustrations are freely available at www. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955564 Tue, 31 Aug 2010 23:00:00 +0100 3955564 http://www.medworm.com/index.php?rid=3955563&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000273%2Fabstract%3Frss%3Dyes represent a series of anatomical abnormalities presenting for emergency surgery in the neonatal period. They present the anaesthetist with cardio-respiratory challenges in the preoperative, intra-operative and postoperative phases. In addition to the consequences of the pathology itself, co-morbidities are very common, which superimpose further considerations. The basic science, anatomy and genetics are discussed as well as the clinical presentation, perioperative management, controversies and complications. The evidence for optimum management is based mostly on expert opinion; there are very few large randomised controlled trials concerning many areas of perioperative management. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955563 Tue, 31 Aug 2010 23:00:00 +0100 3955563 http://www.medworm.com/index.php?rid=3955562&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961000039X%2Fabstract%3Frss%3Dyes Pulmonary hypertension presenting in the neonatal period can be due to congenital heart malformations (most commonly associated with obstruction to pulmonary venous drainage), high output cardiac failure from large arteriovenous malformations and persistent pulmonary hypertension of the newborn (PPHN). Of these, the most common cause is PPHN. PPHN develops when pulmonary vascular resistance (PVR) remains elevated after birth, resulting in right-to-left shunting of blood through foetal circulatory pathways. The PVR may remain elevated due to pulmonary hypoplasia, like that seen with congenital diaphragmatic hernia; maldevelopment of the pulmonary arteries, seen in meconium aspiration syndrome; and maladaption of the pulmonary vascular bed as occurs with perinatal asphyxia. These newborn pat... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955562 Tue, 31 Aug 2010 23:00:00 +0100 3955562 http://www.medworm.com/index.php?rid=3955561&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000315%2Fabstract%3Frss%3Dyes This article aims at reviewing basic physiological considerations important for neonatal fluid management and mainly focusses on fluid maintenance and replacement during surgery. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955561 Tue, 31 Aug 2010 23:00:00 +0100 3955561 http://www.medworm.com/index.php?rid=3955560&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000376%2Fabstract%3Frss%3Dyes This article will describe the different ventilation modes available for neonates and highlight the importance of using a protective and open-lung ventilation strategy, even in the operating room. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955560 Tue, 31 Aug 2010 23:00:00 +0100 3955560 http://www.medworm.com/index.php?rid=3955559&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000352%2Fabstract%3Frss%3Dyes Postoperative apnoea in ex-premature infants is inversely proportional to gestational age at birth and postmenstrual age (PMA). Spinal anaesthesia is an important technique in ex-premature infants as it reduces the risk of postoperative apnoea, provided intra-operative sedation is avoided. Recent studies have provided more data on recommended doses of local anaesthetics for infant spinal anaesthesia as well as adjuvants used to prolong the duration of surgical anaesthesia. Spinal anaesthesia is also used for surgical procedures other than inguinal hernia repair. There are a variety of reasons why awake regional is not the preferred technique for ex-premature infants undergoing lower abdominal surgery in many centres, and there is also controversy over the appropriate anaesthetic technique ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955559 Tue, 31 Aug 2010 23:00:00 +0100 3955559 http://www.medworm.com/index.php?rid=3955558&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000546%2Fabstract%3Frss%3Dyes Premature infants have immature respiratory control that predisposes them to apnoea, haemoglobin oxygen desaturation and bradycardia. Apnoeas are loosely classified, according to the presence or absence of respiratory effort, into central, obstructive or mixed.There are a variety of conditions, in the perioperative period, that predispose an infant to apnoea, including: central nervous system (CNS) lesions, infections and sepsis, ambient temperature fluctuations, cardiac abnormalities, metabolic derangements, anaemia, upper airway structural abnormalities, necrotising enterocolitis, drug administration (including opiates and general anaesthetics) and possibly gastro-oesophageal reflux.Various monitoring techniques are discussed; the mainstay are pulse oximetry and abdominal-pressure transd... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955558 Tue, 31 Aug 2010 23:00:00 +0100 3955558 http://www.medworm.com/index.php?rid=3955557&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000297%2Fabstract%3Frss%3Dyes In conclusion, a large variety of local and regional anaesthetic techniques can be safely used in neonatal patients. The use of such techniques must obviously be associated with sufficient knowledge about the various techniques, as well as adherence to adequate dosage guidelines and other safety precautions. However, if these prerequisites are met, regional anaesthesia may offer great advantages to our smallest and most vulnerable patients. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955557 Tue, 31 Aug 2010 23:00:00 +0100 3955557 http://www.medworm.com/index.php?rid=3955556&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000534%2Fabstract%3Frss%3Dyes Neonatal care is advancing to levels where more neonates are now offered more invasive interventions, exposing them to more prolonged hospital care. Consequently, the provision of effective and consistent management of pain in these neonates has become a pressing challenge. Advances in neonatal care have not only increased the number of neonates, who are exposed to noxious stimuli, but, over recent decades, also altered the patterns of exposure. Both procedural and postoperative pain remain distinct in nature, prevalence and management, and need to be addressed separately. Recent advances in the management of neonatal pain have been facilitated by improved methods of pain assessment and an increased understanding of the developmental aspects of nociception. Over the past decade, there have... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955556 Tue, 31 Aug 2010 23:00:00 +0100 3955556 http://www.medworm.com/index.php?rid=3955555&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000522%2Fabstract%3Frss%3Dyes Caring for a neonate is one of the core challenges for paediatric anaesthetists. Compared to older children and adults, neonates have a substantially different physiology and different concurrent pathologies. Their response to drugs is also frequently different. These challenges are compounded by a relative paucity of research to define their particular physiology and pharmacology, and few studies examining what is best anaesthesia practice in this age group. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955555 Tue, 31 Aug 2010 23:00:00 +0100 3955555 http://www.medworm.com/index.php?rid=3955554&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000601%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3955554 Tue, 31 Aug 2010 23:00:00 +0100 3955554 http://www.medworm.com/index.php?rid=3615213&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000492%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615213 Mon, 31 May 2010 23:00:00 +0100 3615213 http://www.medworm.com/index.php?rid=3615212&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000182%2Fabstract%3Frss%3Dyes Surgery and general anaesthesia have direct effects on the respiratory system depending on the organ/system involved and modality of delivery, potentially leading to postoperative pulmonary complications that increase hospital morbidity, prolong hospital stay and add to health-care costs.Postoperative complications have been reported to be as high as 30% for thoracotomy and lung resection in patients with chronic obstructive pulmonary disease. Most of the complications are due to respiratory muscle dysfunction and surgery-related changes in chest wall mechanics. In general, preoperative optimisation of medical therapy combined with physiotherapy and early extubation and mobilisation may improve clinical outcomes in high-risk surgeries, including upper abdominal and thoracic surgery in pati... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615212 Mon, 31 May 2010 23:00:00 +0100 3615212 http://www.medworm.com/index.php?rid=3615211&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000212%2Fabstract%3Frss%3Dyes Perioperative patient handling should urgently be updated according to current evidence and, if none is available, at least according to physiological knowledge. To prevent pulmonary aspiration, preoperative fasting for 2h (clear fluids) and 6h (solid food) and abdication of 20min for smoking is sufficient. Beta-blockage requires an indication. Bowel preparation should be abandoned and minimal invasive surgery as well as local and regional anaesthesia should be used where possible. Fluid therapy should be rational and requirement-adapted, and hypothermia, postoperative nausea and vomiting, unnecessary drains, tubes and catheters avoided. A multi-modal opioid-sparing pain therapy, sufficient oxygenation as well as early nutrition and mobilisation all play an important role for patient outc... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615211 Mon, 31 May 2010 23:00:00 +0100 3615211 http://www.medworm.com/index.php?rid=3615210&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000248%2Fabstract%3Frss%3Dyes Anaesthesia, postoperative pain and surgery (more so if the site of the surgery approaches the diaphragm) will induce respiratory modifications: hypoxaemia, pulmonary volume decrease and atelectasis associated to a restrictive syndrome and a diaphragm dysfunction. These modifications of the respiratory function occur early after surgery and may induce acute respiratory failure (ARF). Maintenance of adequate oxygenation in the postoperative period is of major importance, especially when pulmonary complications such as ARF occur. Non-invasive ventilation (NIV) refers to techniques allowing respiratory support without the need of endotracheal intubation. Two types of NIV are commonly used: non-invasive continuous positive airway pressure (CPAP) and non-invasive positive pressure ventilation (... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615210 Mon, 31 May 2010 23:00:00 +0100 3615210 http://www.medworm.com/index.php?rid=3615209&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961000025X%2Fabstract%3Frss%3Dyes Spontaneous ventilation during general anaesthesia has been shown to favour atelectasis formation and decreased functional residual capacity. Therefore, general anaesthesia is commonly associated with endotracheal intubation and mechanical ventilation. Laryngeal lesions, residual curarisation, haemodynamics impairment, but most importantly, situation of cannot ventilate – cannot intubate may occur. Recently developed anaesthetic ventilators are able to detect spontaneous ventilation (triggering) and to give a pressure-limited flow cycled assisted breath (pressure support ventilation, PSV). Spontaneous ventilation assisted by PSV with laryngeal mask may avoid all the complications of endotracheal intubation and mechanical ventilation. Therefore, PSV should be a valid alternative for all p... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615209 Mon, 31 May 2010 23:00:00 +0100 3615209 http://www.medworm.com/index.php?rid=3615208&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000170%2Fabstract%3Frss%3Dyes Laparoscopy is widely used in the surgical treatment of a number of diseases. Its advantages are generally believed to lie on its minimal invasiveness, better cosmetic outcome and shorter length of hospital stay based on surgical expertise and state-of-the-art equipment. Thousands of laparoscopic surgical procedures performed safely prove that mechanical ventilation during anaesthesia for laparoscopy is well tolerated by a vast majority of patients. However, the effects of pneumoperitoneum are particularly relevant to patients with underlying lung disease as well as to the increasing number of patients with higher-than-normal body mass index. Moreover, many surgical procedures are significantly longer in duration when performed with laparoscopic techniques. Taken together, these factors im... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615208 Mon, 31 May 2010 23:00:00 +0100 3615208 http://www.medworm.com/index.php?rid=3615206&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000169%2Fabstract%3Frss%3Dyes Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15–20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. Body mass is an important determinant of respiratory function before and during anaesthesia not only in morbidly but also in moderately obese patients. These can manifest as (a) reduced lung volume with increased atelectasis; (b)derangements in respiratory system, lung and chest wall compliance and increased resistance; and (c) moderate to severe hypoxaemia. These physiological alterations are more marked in obese patients with hypercapn... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615206 Mon, 31 May 2010 23:00:00 +0100 3615206 http://www.medworm.com/index.php?rid=3615205&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000224%2Fabstract%3Frss%3Dyes Tidal volumes have tremendously decreased over the last decades from (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615205 Mon, 31 May 2010 23:00:00 +0100 3615205 http://www.medworm.com/index.php?rid=3615204&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000236%2Fabstract%3Frss%3Dyes General anaesthesia induces ventilation/perfusion mismatch by lung collapse. Such lung collapse predisposes patients to preoperative complications since it can persist for several hours or days after surgery.Atelectasis can be partially prevented by using continuous positive airway pressure (CPAP) and/or by lowering FiO2 during anaesthesia induction. However, these manoeuvres are dangerous for patients presenting with challenging airway or ventilator conditions.Lung recruitment manoeuvres (RMs) are ventilatory strategies that aim to restore the aeration of normal lungs. They consist of a brief and controlled increment in airway pressure to open up collapsed areas of the lungs and sufficient positive end-expiratory pressure (PEEP) to keep them open afterward. The application of RMs during a... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615204 Mon, 31 May 2010 23:00:00 +0100 3615204 http://www.medworm.com/index.php?rid=3615203&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000261%2Fabstract%3Frss%3Dyes This study discusses possible mechanisms and interactions between atelectasis formation in the lungs and the development or aggravation of acute lung injury. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615203 Mon, 31 May 2010 23:00:00 +0100 3615203 http://www.medworm.com/index.php?rid=3615202&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000200%2Fabstract%3Frss%3Dyes Atelectasis appears in about 90% of all patients who are anaesthetised. Up to 15–20% of the lung is regularly collapsed at its base during uneventful anaesthesia prior to any surgery being carried out. Atelectasis can persist for several days in the postoperative period. It is likely to be a focus of infection and may contribute to pulmonary complications. A major cause of anaesthesia-induced lung collapse is the use of high oxygen concentration during induction and maintenance of anaesthesia together with the use of anaesthetics that cause loss of muscle tone and fall in functional residual capacity (a common action of almost all anaesthetics). This causes absorption atelectasis behind closed airways. Compression of lung tissue and loss of surfactant or surfactant function are additiona... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615202 Mon, 31 May 2010 23:00:00 +0100 3615202 http://www.medworm.com/index.php?rid=3615201&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000194%2Fabstract%3Frss%3Dyes Postoperative pulmonary complications contribute considerably to morbidity and mortality, especially after major thoracic or abdominal surgery. Clinically relevant pulmonary complications include the exacerbation of underlying chronic lung disease, bronchospasm, atelectasis, pneumonia and respiratory failure with prolonged mechanical ventilation. Risk factors for postoperative pulmonary complications include patient-related risk factors (e.g., chronic obstructive pulmonary disease (COPD), tobacco smoking and increasing age) as well as procedure-related risk factors (e.g., site of surgery, duration of surgery and general vs. regional anaesthesia). Careful history taking and a thorough physical examination may be the most sensitive ways to identify at-risk patients. Pulmonary function tests ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615201 Mon, 31 May 2010 23:00:00 +0100 3615201 http://www.medworm.com/index.php?rid=3615200&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000388%2Fabstract%3Frss%3Dyes The current number of Best Practice & Research Clinical Anaesthesiology deals with the respiratory management of patients during the perioperative period. This is a very important and challenging topic because postoperative pulmonary complications contribute significantly to overall perioperative morbidity and mortality rates. The frequency rate of respiratory complications varies from 5% to 70% depending on variations among studies in the definition of postoperative pulmonary complications, as well as variability in patient-and procedure-related factors. Respiratory complications may prolong the hospital stay by an average of 1–2 weeks, and are likewise associated with increased morbidity and mortality. They account for up to 25% of deaths occurring within a few days of overt respirator... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615200 Mon, 31 May 2010 23:00:00 +0100 3615200 http://www.medworm.com/index.php?rid=3615199&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000455%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3615199 Mon, 31 May 2010 23:00:00 +0100 3615199 http://www.medworm.com/index.php?rid=3323642&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168961000011X%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323642 Mon, 01 Mar 2010 00:00:00 +0100 3323642 http://www.medworm.com/index.php?rid=3323641&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000767%2Fabstract%3Frss%3Dyes One of the greatest disappointments associated with a successful surgical procedure is a thrombotic or thrombo-embolic complication in the postoperative period. Morbidity and mortality of the perioperative period are related, to a relevant degree, to perioperative thrombo-embolic events. Ranging from simple deep venous thrombosis to pulmonary embolism or arterial thrombosis, this class of complication invariably increases length of hospital stay or may result in mortality. The purpose of this review is to identify the procedures and patient populations noted to have thrombophilia in the postoperative period, link the changes in circulating and in situ haematological/biochemical substrates most likely responsible for morbidity, identify the clinical diagnostic modalities that detect recent/... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323641 Mon, 01 Mar 2010 00:00:00 +0100 3323641 http://www.medworm.com/index.php?rid=3323640&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000688%2Fabstract%3Frss%3Dyes This article presents an overview of current guidelines on the use of regional anaesthetic techniques in patients treated with various anticoagulants and also describes a possible strategy to deal with new antithrombotic drugs that have recently been introduced in some countries or will be shortly in others. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323640 Mon, 01 Mar 2010 00:00:00 +0100 3323640 http://www.medworm.com/index.php?rid=3323639&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000780%2Fabstract%3Frss%3Dyes This article provides an overview of the scientific evidence regarding the efficacy and safety of antifibrinolytic agents and desmopressin to reduce surgical blood loss. The synthetic derivatives of lysine are the only antifibrinolytics available in clinical practice since the withdrawal of aprotinin. There is evidence that the prophylactic use of lysine analogues is efficacious in reducing perioperative blood loss in cardiac and major orthopaedic surgery. The impact on exposure to blood transfusion is, however, variable. There is no evidence at present that they improve the overall outcome. Lysine analogues appear to be well tolerated in coronary artery bypass surgery, but less is known regarding their risk–benefit profile in special patient groups. Further studies are needed to elucida... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323639 Mon, 01 Mar 2010 00:00:00 +0100 3323639 http://www.medworm.com/index.php?rid=3323638&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168960900069X%2Fabstract%3Frss%3Dyes Recombinant activated factor VII (rFVIIa) is a haemostatic agent, which was originally developed for the treatment of haemophilia patients with inhibitors against factor FVIII or FIX. The efficacy of rFVIIa in preventing or stopping life-threatening bleeding for these patients has been demonstrated in several studies. Since the first report about the successful use of rFVIIa in a bleeding soldier in 1999, rFVIIa has gained popularity as an adjunct for the treatment of coagulopathy in a wide array of clinical conditions with serious or life-threatening bleeding. The number of case reports and case series documenting the successful use of rFVIIa as last resort to terminate uncontrollable bleeding has steadily grown.Conflicting results have been reported from various studies. Considering the ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323638 Mon, 01 Mar 2010 00:00:00 +0100 3323638 http://www.medworm.com/index.php?rid=3323637&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000755%2Fabstract%3Frss%3Dyes Unexplained intra-operative coagulopathies continue to be a diagnostic and therapeutic dilemma. The pathophysiology behind unexplained intra-operative coagulopathies is of great variety and complexity (pre-existing coagulopathies, dilutional coagulopathy, interactions of medications, etc.). We have shown in prospective studies that patients undergoing elective surgery who develop ’unexplained' intra-operative bleeding have significantly less F. XIII per unit thrombin available at any point in time (i.e., also already preoperatively) than patients without such coagulopathies. The consequence is a significant loss of clot firmness associated with an increase in intra-operative blood loss. Thus, these patients have less cross-linking capacity to begin with, which explains their preoperative... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323637 Mon, 01 Mar 2010 00:00:00 +0100 3323637 http://www.medworm.com/index.php?rid=3323636&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000937%2Fabstract%3Frss%3Dyes Platelets are active metabolising cells that are evolved for the tasks of haemostasis, inflammatory reactions and wound healing. When platelet products are stored in the blood bank a complex series of changes occur, leading to partial activation, up-regulation of inflammatory mediators, cellular morphology changes, loss of cell membrane lipids and micro-particle formation, as well as apoptosis. The resultant coagulation transfusion product has a number of potential expected side effects including fever, alloimmunisation, sepsis, thrombosis and transfusion-related acute lung injury. Of course, these events are occasional side effects yet they are some of the most common potential disasters of transfusion. Platelet transfusions in patients bleeding from thrombocytopaenia or severe platelet s... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323636 Mon, 01 Mar 2010 00:00:00 +0100 3323636 http://www.medworm.com/index.php?rid=3323635&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000718%2Fabstract%3Frss%3Dyes Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. This practice is not supported by the literature, is unlikely to be of benefit and unnecessarily exposes patients to the risks of FFP. The role of FFP in reversing the effects of warfarin anticoagulation is dependent on the clinical context and availability of alternative agents. Although FFP is commonly transfused in patien... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323635 Mon, 01 Mar 2010 00:00:00 +0100 3323635 http://www.medworm.com/index.php?rid=3323634&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168960900072X%2Fabstract%3Frss%3Dyes Interruption or maintenance of anti-platelet agents (APAs) during surgical or invasive procedures is associated with an increase in cardiovascular or haemorrhagic complications, respectively. The pharmacology and indications of aspirin, clopidogrel and prasugrel are summarised. The utility and risks of interruption, the optimal delay between stent implantation and surgery, the appropriate window of preoperative interruption, the potential usefulness of bridging, the safest delay between the end of surgery and resumption of APA are detailed in this review. Some non- evidence-based suggestions are given to help the physicians in their daily clinical practice. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323634 Mon, 01 Mar 2010 00:00:00 +0100 3323634 http://www.medworm.com/index.php?rid=3323633&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000731%2Fabstract%3Frss%3Dyes is the rational diagnostic basis for pro- and anti-thrombotic interventions in patients undergoing emergency and elective surgery. The main goal of perioperative monitoring of haemostasis is to increase safety of patients undergoing surgical procedures.Currently, there is a change in paradigm with (1) increasing implementation of evidence-based approach to preoperative patient evaluation with laboratory coagulation testing secondary to the results of the standardised bleeding history and (2) awareness of the limitations of routine coagulation tests to guide coagulation management in massive bleeding. Alternatively, visco-elastic point-of-care monitoring is increasingly used worldwide. This innovative methodology triggers a trend towards an ‘early goal-directed coagulation management’ ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323633 Mon, 01 Mar 2010 00:00:00 +0100 3323633 http://www.medworm.com/index.php?rid=3323632&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000743%2Fabstract%3Frss%3Dyes Abnormal coagulation parameters can be found in 25% of trauma patients with major injuries. Furthermore, trauma patients presenting with coagulopathy on admission have worse clinical outcome. Tissue trauma and systemic hypoperfusion appear to be the primary factors responsible for the development of acute traumatic coagulopathy immediately after injury. As a result of overt activation of the protein C pathway, the acute traumatic coagulopathy is characterised by coagulopathy in conjunction with hyperfibrinolysis. This coagulopathy can then be exacerbated by subsequent physiologic and physical derangements such as consumption of coagulation factors, haemodilution, hypothermia, acidemia and inflammation, all factors being associated with ongoing haemorrhage and inadequate resuscitation or tr... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323632 Mon, 01 Mar 2010 00:00:00 +0100 3323632 http://www.medworm.com/index.php?rid=3323631&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000706%2Fabstract%3Frss%3Dyes Perioperative coagulopathy impacts on patient outcome by influencing final blood loss and transfusion requirements. The recognition of pre-existing disturbances and the basic understanding of the principles of and dynamic changes of haemostasis during surgery are pre-conditions for safe patient management. The newly developed cellular model of coagulation facilitates the understanding of coagulation, thereby underscoring the importance of the tissue factor-bearing cell and the activated platelet. Amount of blood loss as well as amount and type of fluids used are the main factors involved in the development of dilutional coagulopathy, which is the most frequently observed cause of coagulopathy in the otherwise healthy surgical patient. Recent data from studies using viscoelastic coagulation... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323631 Mon, 01 Mar 2010 00:00:00 +0100 3323631 http://www.medworm.com/index.php?rid=3323630&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000925%2Fabstract%3Frss%3Dyes In the past years, there has been a renewed interest in haemostasis and its management in the perioperative period. The clotting cascade has been replaced by a cell-based representation of coagulation and there has been a thorough interest to understand not only a single part but the overall picture of the coagulation system in the perioperative period with its pro-coagulant as well as anti-coagulant and fibrinolytic control mechanisms. Furthermore, a new respect for the endothelium as an active driver of these processes has been established recently. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323630 Mon, 01 Mar 2010 00:00:00 +0100 3323630 http://www.medworm.com/index.php?rid=3323629&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689610000078%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3323629 Mon, 01 Mar 2010 00:00:00 +0100 3323629 http://www.medworm.com/index.php?rid=3053659&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000895%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053659 Tue, 01 Dec 2009 00:00:00 +0100 3053659 http://www.medworm.com/index.php?rid=3053658&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000512%2Fabstract%3Frss%3Dyes This article presents a template for judging trials of tight glucose control in critically ill patients. It reviews threats to both internal validity and generalisability using examples from the current literature. When judging internal validity, it is important to consider factors specific to trials of glucose control (particularly the methods of glucose control, measurement and reporting) in addition to factors common to all randomised controlled trials (such as treatment allocation, losses to follow-up and protocol violations). Judging generalisability requires the identification of differences between the trial population and the population for whom the intervention is being considered. These may relate to the setting, the patients or the practical delivery of tight glucose control or ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053658 Tue, 01 Dec 2009 00:00:00 +0100 3053658 http://www.medworm.com/index.php?rid=3053657&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000664%2Fabstract%3Frss%3Dyes Tight glycaemic control (TGC) for patients treated in an intensive care unit ICU is associated with an increased risk for hypoglycaemia. Since hypoglycaemia mainly occurs in the sickest patients, no matter whether TGC is applied or not, it might be a marker for severity of illness or a harmful event in itself. Furthermore, it remains a matter of debate whether harmful effects of hypoglycaemia outbalance the clinical benefits of TGC. This review focusses on the clinical manifestations of hypoglycaemia in the critically ill and highlights its potential short- and long-term consequences specifically concerning neurocognitive function. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053657 Tue, 01 Dec 2009 00:00:00 +0100 3053657 http://www.medworm.com/index.php?rid=3053656&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000652%2Fabstract%3Frss%3Dyes This article offers the clinical anesthesiologist direction for the organisation of inpatient blood glucose control in acute situations, in the perioperative setting and in the intensive care unit. An effective, safe and user-friendly algorithm for intravenous insulin administration is presented that can be executed by regular nurses and used in many situations. Practical advice is offered for the use of subcutaneous basal–bolus insulin, for fasting orders and for transition to discharge care. The main safety considerations are discussed. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053656 Tue, 01 Dec 2009 00:00:00 +0100 3053656 http://www.medworm.com/index.php?rid=3053655&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000524%2Fabstract%3Frss%3Dyes High blood glucose levels have been associated with morbidity and poor outcome in critically ill patients, irrespective of underlying pathology. In a large, randomised, controlled study the use of insulin therapy to maintain normoglycaemia for at least a few days improved survival and reduced morbidity of patients who are in a surgical intensive care unit (ICU). Since the publication of this landmark study, several other investigators have provided support for, whereas others have questioned, the beneficial effects of intensive insulin therapy.In this review, we discuss the investigated potential molecular mechanisms behind the clinical benefits of intensive insulin therapy. We first describe the molecular origin of hyperglycaemia and the impact of the therapy on insulin sensitivity. Next,... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053655 Tue, 01 Dec 2009 00:00:00 +0100 3053655 http://www.medworm.com/index.php?rid=3053654&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000469%2Fabstract%3Frss%3Dyes Hyperglycaemia and glucose variability occur frequently during critical illness or after major surgery in children and are associated with worse outcome. Association does not necessarily imply causality however, and the question whether tight glycaemic control (TGC) with insulin infusion improves morbidity and mortality can only be answered by randomised controlled trials (RCTs). Currently, only one single-centre RCT exists, proving the concept of TGC in critically ill children. Attenuation of inflammation and reduction of secondary infections, decreased prolonged stay in intensive care and reduced dependency on haemodynamic support were accomplished, despite a substantial increased incidence of biochemical hypoglycaemia. Before universal implementation in paediatric intensive care both lo... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053654 Tue, 01 Dec 2009 00:00:00 +0100 3053654 http://www.medworm.com/index.php?rid=3053653&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000470%2Fabstract%3Frss%3Dyes Acute kidney injury is a frequent and life-threatening complication of critical illness. Prevention of this condition is crucial. Two randomized single center trials in critically ill patients have shown a decrease in acute kidney injury by tight glycaemic control, an effect that appears most pronounced in surgical patients. Subsequent randomized trials did not confirm this renoprotective effect. This apparent contradiction is likely explained by methodological differences between studies, including different patient populations, insufficient patient numbers, comparison with a different control group, use of inaccurate blood glucose analyzers, and differences in the degree of reaching the target blood glucose level. The optimal glycaemic target for renoprotection in critical illness remain... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053653 Tue, 01 Dec 2009 00:00:00 +0100 3053653 http://www.medworm.com/index.php?rid=3053652&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000482%2Fabstract%3Frss%3Dyes While stress hyperglycaemia has traditionally been regarded as an adaptive, beneficial response, it is clear that hyperglycaemia and hypoglycaemia are associated with increased risk of death in critically ill intensive care unit (ICU) patients. Recent studies on blood-glucose control failed to fully clarify whether this association is causal. Early proof-of-concept single-centre randomised controlled studies found that maintaining normoglycaemia by intensive insulin therapy, as compared with tolerating hyperglycaemia as an adaptive response, improved patient outcome. However, recent large multicentre studies VISEP, GLUCONTROL and NICE-SUGAR) could not confirm this survival benefit.Methodological disparity in the execution of the complex intervention of tight glycaemic control may have cont... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053652 Tue, 01 Dec 2009 00:00:00 +0100 3053652 http://www.medworm.com/index.php?rid=3053651&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000792%2Fabstract%3Frss%3Dyes The benefits of tight glycaemic control (TGC) were first shown in cardiac surgical patients with diabetes. These concepts migrated to other surgical and medical specialties through intensive care units caring for a variety of patients with a variety of disease states. Although some disagreement and controversy surrounds the use of TGC in the medical population, the benefits of this therapy in the diabetes cardiac surgery population is unblemished. Perioperative hyperglycaemia has been shown to be associated with adverse surgical outcomes in several different patient populations. TGC for 3 full postoperative days or more mitigates these risks. Although this has been definitively proven in the diabetes coronary artery bypass graft (CABG) population, evidence for beneficial effects of TGC in... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053651 Tue, 01 Dec 2009 00:00:00 +0100 3053651 http://www.medworm.com/index.php?rid=3053650&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000494%2Fabstract%3Frss%3Dyes This article summarises the present understanding of the mechanisms behind the positive clinical effects and gives an overview of the information available regarding the clinical effects of this treatment. Finally, the article summarises the most recently published national guidelines on preoperative fasting routines where preoperative carbohydrates are recommended for use before a major surgery. These are to be considered for all patients allowed to drink clear fluids and undergoing elective surgery. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053650 Tue, 01 Dec 2009 00:00:00 +0100 3053650 http://www.medworm.com/index.php?rid=3053649&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000676%2Fabstract%3Frss%3Dyes Hyperglycaemia is commonly found in critically ill patients as a result of numerous processes such as increased gluconeogenesis and glycogenolysis caused by elevated levels of corresponding hormones and insulin resistance. As the clinical consequence of hyperglycaemia has been shown to increase morbidity and mortality in various clinical settings, many hospitals by now use tight glycaemic control protocols for their patients in intensive care units to maintain normoglycaemia. The success of the intensive insulin therapy depends crucially on frequent and accurate blood glucose measurements with immediate feedback of results. Therefore, in almost all cases, this will be done by point-of-care testing methods, raising the question of how accurately blood glucose levels are actually measured an... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053649 Tue, 01 Dec 2009 00:00:00 +0100 3053649 http://www.medworm.com/index.php?rid=3053648&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000500%2Fabstract%3Frss%3Dyes Stress hyperglycaemia is a distinctive clinical feature of critical illness. Stress mediators, namely stress hormones, cytokines and the central nervous system, interfere with normal carbohydrate metabolism, especially in the liver and skeletal muscle. Central insulin resistance, defined as increased hepatic gluconeogenesis and glucose output despite abundant endogenous insulin levels, appears pivotal to the occurrence of stress hyperglycaemia. The skeletal muscle is refractory to insulin action too. Peripheral insulin resistance is predominantly attributed to inhibition of the skeletal muscle glycogen synthesis. Significantly increased non-insulin-mediated glucose transport into the skeletal muscle overrules defective insulin-mediated glucose transport.Inflammatory mediators and counter-r... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053648 Tue, 01 Dec 2009 00:00:00 +0100 3053648 http://www.medworm.com/index.php?rid=3053647&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000779%2Fabstract%3Frss%3Dyes This issue of Best Practice and Research-Clinical Anesthesiology is dedicated to tight glycaemic control during the perioperative and critically ill phase of patients being admitted to intensive care units. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053647 Tue, 01 Dec 2009 00:00:00 +0100 3053647 http://www.medworm.com/index.php?rid=3053646&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000858%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=3053646 Tue, 01 Dec 2009 00:00:00 +0100 3053646 http://www.medworm.com/index.php?rid=2783276&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000627%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783276 Mon, 31 Aug 2009 23:00:00 +0100 2783276 http://www.medworm.com/index.php?rid=2783275&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000457%2Fabstract%3Frss%3Dyes This article covers current provision of training in echocardiography and ultrasound in areas relevant to anaesthetists who are working in critical care (including accident and emergency) and complex surgery (mainly cardiac). (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783275 Mon, 31 Aug 2009 23:00:00 +0100 2783275 http://www.medworm.com/index.php?rid=2783274&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000263%2Fabstract%3Frss%3Dyes Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. ... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783274 Mon, 31 Aug 2009 23:00:00 +0100 2783274 http://www.medworm.com/index.php?rid=2783273&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000196%2Fabstract%3Frss%3Dyes The dislodgement of atheroma from the ascending aorta and proximal arch is a major cause of stroke and neurological injury following cardiac surgery. The accurate detection of atheroma prior to aortic manipulation is necessary to facilitate surgical strategies to reduce the risk of embolisation.The traditional method for atheroma detection is manual palpation by the surgeon. This technique misses about half the number of the atheroma lesions, as the soft (non-calcified) lesions offer little resistance to the surgeon's fingers. Trans-oesophageal echocardiography (TOE) is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the oesophagus causes an ultrasound ‘blind spot’ in the ascending aorta and proximal arch, such that it does not offer improv... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783273 Mon, 31 Aug 2009 23:00:00 +0100 2783273 http://www.medworm.com/index.php?rid=2783272&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000275%2Fabstract%3Frss%3Dyes Major surgery is associated with significant trauma and is a potential cause of multiple system organ failure and death. Measurement of cardiac output using a variety of techniques during the perioperative period has enabled practitioners to proactively optimise stroke volume and cardiac output in an attempt to reduce postoperative complications. Although pulmonary artery catheter has been widely used and considered as the gold standard for measuring cardiac output, recent advancement of technology has seen the development of a number of less-invasive haemodynamic monitors. Oesophageal Doppler ultrasonography is a minimally invasive method for measuring stroke volume and cardiac output. It is user-friendly and is one of the few low-invasive technologies to date, which has been used success... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783272 Mon, 31 Aug 2009 23:00:00 +0100 2783272 http://www.medworm.com/index.php?rid=2783271&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000202%2Fabstract%3Frss%3Dyes This article focusses on the recent growing evidence to support the benefits of its use in nerve and plexus blocks. Common complications of nerve blocks can be avoided with ultrasound but have still been reported. Anatomical variants have been demonstrated by ultrasound and it has proved to be useful in performing regional anaesthesia in difficult situations or where peripheral nerve stimulation is unsuccessful or inappropriate. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783271 Mon, 31 Aug 2009 23:00:00 +0100 2783271 http://www.medworm.com/index.php?rid=2783270&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000214%2Fabstract%3Frss%3Dyes This article summarises the literature on complication rates, efficacy and safety of ultrasound-guided vascular access procedures and describes a practical method of ultrasound-guided central venous access and arterial catheterisation. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783270 Mon, 31 Aug 2009 23:00:00 +0100 2783270 http://www.medworm.com/index.php?rid=2783269&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000238%2Fabstract%3Frss%3Dyes The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. A parallel development has been the concept of limited transthoracic echocardiography that can be performed by practitioners with limited experience. The basis of these examinations is to provide the practising clinician with immediate information to help guide management with a focus on haemodynamic evaluation, and limited structural (valve) assessme... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783269 Mon, 31 Aug 2009 23:00:00 +0100 2783269 http://www.medworm.com/index.php?rid=2783268&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000226%2Fabstract%3Frss%3Dyes The haemodynamic state refers to the integration of myocardial and vascular systems, and involves both left and right hearts, and systolic and diastolic phases. The assessment of the haemodynamic state can be performed with echocardiography, and provides a higher level of diagnosis than conventional pressure- and flow-based monitoring. Whilst hypotension alerts the practitioner about the existence of haemodynamic abnormality, it does not provide sufficient information to identify the cause or the underlying haemodynamic state. The premise of haemodynamic state monitoring is that better diagnosis will lead to more rational therapy, which in turn may improve the outcome.The haemodynamic state can be classified into seven broad categories: normal, empty, vasodilation, systolic failure, primar... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783268 Mon, 31 Aug 2009 23:00:00 +0100 2783268 http://www.medworm.com/index.php?rid=2783267&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168960900024X%2Fabstract%3Frss%3Dyes Trans-oesophageal echocardiography (TOE) has profoundly changed cardiac surgery and the role of the cardiac anaesthesiologist. It has been the driving force for a real-time diagnostic and decision-making partnership between cardiac anaesthesiologists and cardiac surgeons that has significantly advanced the safety and effectiveness of modern cardiac surgery. With the information provided by TOE, anaesthesiologists and surgeons may redirect the care of cardiac surgical patients to decrease morbidity and mortality. As a result, routine intra-operative TOE is an expectation in many cardiac surgical practices. While some colleagues continue to question whether TOE should be used routinely in all cardiac surgical patients, we believe that it is impossible to predict in which cardiac patients TOE... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783267 Mon, 31 Aug 2009 23:00:00 +0100 2783267 http://www.medworm.com/index.php?rid=2783266&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000251%2Fabstract%3Frss%3Dyes Echography has developed as an indispensable tool in diagnosis and subsequent therapy in the critically ill. Although pulmonary and abdominal ultrasounds play a major role in their management, this article will discuss the advantages and indications of echocardiography in the intensive care unit (ICU). The assessment of morphological abnormalities, left or right ventricular malfunction, pulmonary arterial hypertension and valvular dysfunctions is a routine indication of echocardiography. Actually, besides contractility, several preload and even afterload indicators can also be assessed. In short, this bedside tool rapidly provides insight in the haemodynamics without invasive pressure estimations. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783266 Mon, 31 Aug 2009 23:00:00 +0100 2783266 http://www.medworm.com/index.php?rid=2783265&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000044%2Fabstract%3Frss%3Dyes This article gives the anaesthesiolgoist an overview about the relevant indications for ultrasound in non-cardiac surgical patients. Other chapters will focus in more detail on different aspects of ultrasound use in non-cardiac anaesthesia.Echocardiography is a monitoring tool for cardiac structures and function. In the anaesthetized patient the transoesophageal approach is preferred due to the unrestricted ultrasound view to the heart. Its use for non-cardiac surgery is discussed.The use of transcutaneous ultrasound in anaesthesia is mainly interventional: The puncture rate for vascular access e.g. central venous catheterization is higher and the procedure can be performed safer under continuous sonographic guidance.Nerve blockade under direct visualisation of target and accompanying stru... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783265 Mon, 31 Aug 2009 23:00:00 +0100 2783265 http://www.medworm.com/index.php?rid=2783264&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000445%2Fabstract%3Frss%3Dyes When I first learnt echocardiography in 1995, it was with the cardiologists and therefore predominantly transthoracic echocardiography. As a cardiac anaesthetist, I had to use transoesophageal echocardiography, and furthermore, it had to be at an advanced or diagnostic level. This was hampered by few standards and even fewer educational materials. It was terribly controversial, with many practitioners more concerned about the risk of oesophageal rupture, rather than the potential benefit that echocardiography could provide to patients undergoing cardiac surgery. In cardiac anaesthesia, the uptake of TOE was very rapid, becoming a standard of care in many institutions world wide. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783264 Mon, 31 Aug 2009 23:00:00 +0100 2783264 http://www.medworm.com/index.php?rid=2783263&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000585%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2783263 Mon, 31 Aug 2009 23:00:00 +0100 2783263 http://www.medworm.com/index.php?rid=2470156&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689609000391%2Fabstract%3Frss%3Dyes (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470156 Mon, 01 Jun 2009 04:00:00 +0100 2470156 http://www.medworm.com/index.php?rid=2470155&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689608000992%2Fabstract%3Frss%3Dyes Haemostatic alterations associated with the use of fluids are related to non-specific dilutional effects and colloid-specific effects, such as acquired von Willebrand syndrome, inhibition of platelet function and fibrin polymerization. Judging by currently available evidence, dextran, hetastarch and pentastarch have a more pronounced impact than tetrastarch, gelatin and albumin. In patients with hypocoagulability, tetrastarch appears to be a suitable volume expander due to its high safety index and volume efficacy. Gelatins have lower inhibitory effects on clot strength compared with tetrastarch, but their volume efficacy is also lower. Dextrans are potent anticoagulants with a high risk for adverse reactions. Albumin has negligible effects on haemostasis, but low volume efficacy and costs... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470155 Mon, 01 Jun 2009 04:00:00 +0100 2470155 http://www.medworm.com/index.php?rid=2470154&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689608001006%2Fabstract%3Frss%3Dyes Peri-operative fluid therapy continues to be an exercise in empiricism, with nagging questions about efficacy and complications. Pharmacokinetics is used for studying the time dependency of administered drugs. Volume kinetics is a pharmacokinetic approach describing the peak effects and clearance of intravenously infused fluids. It clarifies the absorption, distribution, metabolism and excretion of an intravenous fluid bolus. This could possibly allow for more rational design of intravenous fluid paradigms to improve clinical fluid therapy. This chapter briefly summarizes currently accepted principles of fluid therapy, discusses the general approach to kinetic analysis of fluid therapy, reviews currently available data defining kinetic responses to fluid therapy, and speculates about futur... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470154 Mon, 01 Jun 2009 04:00:00 +0100 2470154 http://www.medworm.com/index.php?rid=2470153&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689608000980%2Fabstract%3Frss%3Dyes Current guidelines on initial haemodynamic stabilization in shock states suggest infusion of either natural or artificial colloids or crystalloids. However, as the volume of distribution is much larger for crystalloids than for colloids, resuscitation with crystalloids alone requires more fluid and results in more oedema, and may thus be inferior to combination therapy with colloids. This chapter describes the currently available synthetic colloid solutions [i.e. dextran, gelatin and hydroxyethyl starch (HES)] in detail, and critically discusses their specific effects including potential adverse effects. Literature was selected from medical databases (including Medline and the Cochrane library), as well as references extracted from the available publications. Dextrans appear to have the mo... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470153 Mon, 01 Jun 2009 04:00:00 +0100 2470153 http://www.medworm.com/index.php?rid=2470152&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689608001018%2Fabstract%3Frss%3Dyes The relevance of albumin administration in the critical care setting remains controversial. We know that albumin has numerous important physiological effects and many potentially beneficial effects in critical illness. We also know that hypoalbuminaemia is common in critically ill patients and is associated with worse outcomes. And we know that routine administration of albumin for fluid resuscitation is not warranted. Albumin may be useful in some patients, especially those with hypoalbuminaemia at risk of complications or those with liver insufficiency. Further studies are needed to clarify what precise role albumin has in today's ICU. (Source: Best Practice and Research. Clinical Anaesthesiology) Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470152 Mon, 01 Jun 2009 04:00:00 +0100 2470152 http://www.medworm.com/index.php?rid=2470151&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS1521689608001031%2Fabstract%3Frss%3Dyes Disorders of fluid and electrolyte balance in the critically ill are volume-related, compositional, or both. Targeting ‘normal’ values for plasma volume, osmolality and electrolytes might not be optimal in conditions as diverse as intracranial trauma/haemorrhage, hepatic encephalopathy, abdominal hypertension, or major surgery, because a hyperosmolar state seems to favourably affect tissue (brain and intestinal) oedema formation. However, adequately powered studies regarding the impact of hypertonic saline on outcome are lacking. Isotonic crystalloids are the cornerstone of resuscitation and must be balanced against natural or artificial colloids and vasopressors. Crystalloid resuscitation is superior to vasopressors in shock associated with blunt trauma, and is at least not inferior t... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470151 Mon, 01 Jun 2009 04:00:00 +0100 2470151 http://www.medworm.com/index.php?rid=2470150&cid=s_37059_5_f&fid=37059&url=http%3A%2F%2Fwww.clinicalanaesthesiology.com%2Farticle%2FPIIS152168960800102X%2Fabstract%3Frss%3Dyes Hypovolaemia is a common cause of circulatory failure in the perioperative period. However, only 50% of critically ill patients respond to volume expansion with an adequate increase in cardiac output. Therefore, in daily clinical practice it is still a challenge to assess each subject's individual position on the Starling curve in order to optimize cardiac preload and avoid deleterious fluid overload. Recently, systolic pressure variation, stroke volume variation, and pulse pressure variation have been introduced as dynamic variables of fluid responsiveness which reflect ventilation-induced cyclic changes in left ventricular stroke volume. The concept of fluid responsiveness has been recognized for more than 20 years, and several studies have shown the superiority of these dynamic variable... Best Practice and Research. Clinical Anaesthesiology journals http://www.medworm.com/rss/comments.php?id=2470150 Mon, 01 Jun 2009 04:00:00 +0100 2470150