Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2012
ReviewReview article: closed-loop systems in anesthesia: is there a potential for closed-loop fluid management and hemodynamic optimization?
Closed-loop (automated) controllers are encountered in all aspects of modern life in applications ranging from air-conditioning to spaceflight. Although these systems are virtually ubiquitous, they are infrequently used in anesthesiology because of the complexity of physiologic systems and the difficulty in obtaining reliable and valid feedback data from the patient. Despite these challenges, closed-loop systems are being increasingly studied and improved for medical use. ⋯ First, the further description and development of dynamic predictors of fluid responsiveness provides a strong parameter for use as a control variable to guide fluid administration. Second, rapid advances in noninvasive monitoring of cardiac output and other hemodynamic variables make goal-directed therapy applicable for a wide range of patients in a variety of clinical care settings. In this article, we review the history of closed-loop controllers in clinical care, discuss the current understanding and limitations of the dynamic predictors of fluid responsiveness, and examine how these variables might be incorporated into a closed-loop fluid administration system.
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Anesthesia and analgesia · Jan 2012
Review Case ReportsReview article: unexpected bleeding in the operating room: the role of acquired von Willebrand disease.
Acquired von Willebrand disease (AvWD) is a rare bleeding disorder that occurs in association with a variety of underlying disorders and can lead to unforeseen bleeding in surgical patients. Cardiovascular as well as malignant and immunological diseases may be associated with AvWD, and several pathophysiological mechanisms have been proposed. von Willebrand factor (vWF) is a plasma glycoprotein that mediates platelet adhesion to subendothelial collagen and causes platelet aggregation under high shear stress. Additionally, vWF acts as a specific carrier for coagulation factor VIII (FVIII) in the plasma. ⋯ In cases of unresponsiveness to standard therapy, recombinant activated factor VIIa may be an alternative option. However, the most effective therapy is the resolution of the underlying disease. In the present review, we focus on the current understanding of AvWD, outlining the associated disorders, underlying pathophysiological mechanisms, and possible treatment options.
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Anesthesia and analgesia · Jan 2012
Multicenter StudyThe epidemiology of upper airway injury in patients undergoing major surgical procedures.
Airway injury is a potentially serious and costly adverse event of anesthesia care. The epidemiologic characteristics of airway injury have not been well documented. ⋯ The risk of airway injury for patients undergoing major surgical procedures is approximately 1 in 500. Patients with difficult airways as indicated by Mallampati classes III and IV are at significantly increased risk of sustaining airway injury during anesthesia for major surgical procedures.
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Simulation can be used to teach technical skills, to evaluate clinician performance, to help assess the safety of the environment of care, and to improve teamwork. Each of these has been successfully demonstrated in obstetric anesthesia simulation. Task simulators for epidural placement, failed intubation, and blood loss estimation seem to improve performance. ⋯ Finally, simulation can effectively assess and teach teamwork tools and behaviors. It is unclear, however, how well the lessons learned in the simulated environment translate into improved behaviors or better care in the clinical setting, or whether simulation improves patient outcomes. More research is needed to help answer these questions.
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Anesthesia and analgesia · Jan 2012
Case ReportsCase report: separation from cardiopulmonary bypass with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot.
Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway obstruction is an extremely rare event found almost exclusively in the intensive care unit. We describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope, without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway bleeding after bronchial disimpaction to separate from CPB.