Annales françaises d'anesthèsie et de rèanimation
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Ann Fr Anesth Reanim · Jul 2014
ReviewIntraoperative management of heart-lung interactions: "From hypothetical prediction to improved titration"
Extensive literature describes the suitability of dynamic parameters to predict responsiveness in fluid. However, based on heart-lung interactions, these parameters can have serious limitations, including the use of protective lung ventilation. ⋯ In this context, the attending physician could, alternatively, titrate the need of fluids with a small fluid challenge, which remains unaffected by low tidal volume, the presence of arrhythmia, or the presence of spontaneous ventilation. When intraoperative prediction of fluid responsiveness is required in mechanically ventilated patients, "improved" titration should be preferred to a hypothetical prediction.
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Ann Fr Anesth Reanim · Jul 2014
ReviewHow to preoxygenate in operative room: Healthy subjects and situations "at risk"
Intubation is one of the most common procedures performed in operative rooms. It can be associated with life-threatening complications when difficult airway access occurs, in patients who cannot tolerate even a slight hypoxemia or when performed in patients at risk of oxygen desaturation during intubation, as obese, critically-ill and pregnant patients. To improve intubation safety, preoxygenation is a major technique, extending the duration of safe apnoea, defined as the time until a patient reaches an arterial saturation level of 88% to 90%, to allow for placement of a definitive airway. ⋯ Recent studies have indicated that in order to maximize the value of preoxygenation (i.e, oxygenation stores) obese and critically-ill patients can benefit from the combination of breathing 100% oxygen and non-invasive positive pressure ventilation (NIV) with end-expiratory positive pressure (PEEP) in the proclive position (Trendelenburg reverse). Recruitment manoeuvres may be of interest immediately after intubation to limit the risk of lung derecruitment. Further studies are needed in the field of preoxygenation in pregnant women.
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One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but survive to leave hospital have often reduced functional independence and long-term survival. Mechanical ventilation provides a specific example that may help us to shift thinking from treatment to prevention of postoperative complications. ⋯ Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung protective mechanical ventilation. In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of mechanical ventilation in patients undergoing abdominal surgery.
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During the past few years, many manufacturers have developed a new generation anesthesia ventilators or anesthesia workstations with innovative technology and introduced so-called new ventilatory modes in the operating room. The aim of this article is to briefly explain how an anesthesia ventilator works, to describe the main differences between the technologies used, to describe the main criteria for evaluating technical and pneumatic performances and to list key elements not to be forgotten during the process of acquiring an anesthesia ventilator.
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The incidents related to the medical devices are common during anesthesia and in intensive care unit. These incidents are rarely the cause of complications because monitoring detects them early; alternative scenarios allow bearing these problems. Although the incidence of these complications has much declined, these incidents are serious adverse events and at the origin of life-threatening complications. ⋯ Several actions are effective in preventing the occurrence of these incidents: the control before use, the continuation of the performance of the equipment, use based on the recommendations of the experts and manufacturers and appropriate training. This strategy is best applied by a clinical expert who has extensive technical knowledge. This expert is a key player for users learning and allows establishing and maintaining rules of use in collaboration with medical staff and biomedical engineers and manufacturers.