Anesthesia and analgesia
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Anesthesia and analgesia · Dec 2011
ReviewPharmacogenomics of β-adrenergic receptor physiology and response to β-blockade.
Myocardial β-adrenergic receptors (βARs) are important in altering heart rate, inotropic state, and myocardial relaxation (lusitropy). The β1AR and β2AR stimulation increases cyclic adenosine monophosphate concentration with the net result of myocyte contraction, whereas β3AR stimulation results in decreased inotropy. Downregulation of β1ARs in heart failure, as well as an increased β3AR activity and density, lead to decreased cyclic adenosine monophosphate production and reduced inotropy. ⋯ Although βAR SNPs may not directly cause disease, they appear to be risk factors for, and modifiers of, disease and the response to stress and drugs. In the perioperative setting, this has specifically been demonstrated for the Arg389Gly β1AR polymorphism with which patients with the Gly variant had a higher incidence of adverse perioperative events. Knowing that genetic variants play an important role, perioperative medicine will likely change from simple therapeutic intervention to a more personalized way of adrenergic receptor modulation.
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Anesthesia and analgesia · Dec 2011
ReviewBrief preoperative smoking abstinence: is there a dilemma?
The concern that stopping smoking shortly (<8 weeks) before surgery increases postoperative pulmonary complications poses a barrier to tobacco use interventions in surgical patients. We show how this concern arose from a misinterpretation of initial studies and has remained in the medical literature despite the accumulation of later evidence. The persistence of unsubstantiated concepts is not uncommon and can have a significant impact on medical practice. Although it may take several weeks to derive pulmonary benefit from quitting, fear of an increase in pulmonary complications should not be a barrier for clinicians to help their patients quit smoking at any time before surgery.
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Anesthesia and analgesia · Dec 2011
ReviewActivation of the hemostatic system during cardiopulmonary bypass.
Cardiopulmonary bypass (CPB) is a unique clinical scenario that results in widespread activation of the hemostatic system. However, surgery also results in normal increases in coagulation activation, platelet activation, and fibrinolysis that are associated with normal wound hemostasis. Conventional CPB interferes with normal hemostasis by diluting hemostatic cells and proteins, through reinfusion of shed blood, and through activation on the bypass circuit surface of multiple systems including platelets, the kallikrein-kinin system, and fibrinolysis. ⋯ Additionally, strategies used to reduce this activation are discussed, including limiting cardiotomy suction, increasing circuit biocompatibility, antithrombin supplementation, and antifibrinolytic use. Determining which patients will most benefit from specific therapies will ultimately require investigation into genetic phenotypes of coagulation protein expression. Until that time, however, a combination of approaches to reduce the hemostatic activation from CPB seems warranted.
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Anesthesia and analgesia · Dec 2011
Review Comparative StudyWhen right is right and when it's not: laterality in cardiac structures.
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Anesthesia and analgesia · Dec 2011
Review Case ReportsApparent dexmedetomidine-induced polyuric syndrome in an achondroplastic patient undergoing posterior spinal fusion.
A 40-year-old achondroplastic patient underwent posterior spinal fusion under general endotracheal anesthesia. Anesthesia was maintained with isoflurane, and sufentanil, dexmedetomidine, and lidocaine infusions. Urine output increased from 150 mL/hr to 950 mL/hr the fourth hour. ⋯ Within 2 hours of discontinuing the dexmedetomidine infusion urine output greatly decreased. Within 24 hours all signs of the polyuric syndrome resolved spontaneously. Alpha(2) agonists block arginine-vasopressin release and action; however, a polyuric syndrome has not been reported in the human literature.