Annales françaises d'anesthèsie et de rèanimation
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The identification of nutritional status is one of the objectives of the anaesthesia consultation often difficult to achieve routinely. It usually requires the use of multiple indicators, which are complex for a non-nutrition specialist. ⋯ To facilitate this evaluation, we propose a stratification of nutritional risk in four grades (NG) using three types of simple and validated parameters: preoperative nutritional status (BMI, weight loss, eventually serum albumin), comorbidities and kind of surgery. This stratification can develop a tailored nutritional care for each patient.
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Although surgery of brain tumors and epilepsy are restricted to few specialized centers, anaesthesia for a patient with epilepsy is commonly encountered. Surgical treatments of epilepsy are currently soaring due to the lack of significant progress about effectiveness of antiepileptic drugs (AEDs). ⋯ Practically, the risk of severe perioperative complications is low, provided that the administration of AEDs is kept as close as possible to its usual dosage, and that metabolic disturbances are prevented. The main anaesthetic drugs to avoid are alfentanil, remifentanil and sevoflurane, although their contraindication are only relative, since the clinical benefit might be clear and the doses should remain moderate.
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Infections are a major cause of death and morbidity after acute injury of the central nervous system (CNS). Acute lesions of the CNS alter immune homeostasis contributing to the development of immunosuppression (IS), and making the bed of the infection. IS results in a decreased phagocytic functions of neutrophils and macrophages as well as monocyte deactivation (decreased capacity of antigen presentation to lymphocytes). ⋯ Specialized units of care for ischemic stroke, taking into account the risk of infection related to the IS, have improved the prognosis until 18th month after the initial damage of the SNC. It is now well recognized that the improved long-term prognosis is related with the secondary prevention of recurrent ischaemia as well as aggressive management of pulmonary infections. A better understanding of the pathophysiology of IS can be considered in the near future, opening the door to immunomodulatory therapeutic trials.
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Ann Fr Anesth Reanim · Jun 2012
Review[Pituitary insufficiency after traumatic brain injury: consequences? Screening?].
Traumatic brain injury has been considered for long as a rare cause of hypopituitarism. Recent studies have already shown a prevalence of 30% of pituitary dysfunction following moderate or severe head injury that may persist into the chronic phase of recovery, hypogonadism and GH deficiency being the most common hormonal deficiencies. ⋯ However, there are limited data available regarding the impact of hypopituitarism, and the indications of hormonal replacement (especially GH replacement and hypogonadism treatment) still remain to be defined. The screening strategy for TBI - induced hypopituitarism has recently been revised.
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Ann Fr Anesth Reanim · Jun 2012
Review[Awake surgery for brain gliomas: plea for an increased involvement of anesthesiologists].
The recent development of awake surgery in neuro-oncology allowed a conceptual change, i.e. the realization of resection for invasive brain tumors according to functional and not anatomic boundaries. This paradigmatic shift enabled a significant improvement of results in surgery for gliomas, by opening the door to resections within eloquent areas classically considered as "inoperable", while preserving and even improving the quality of life of patients. In addition, the extent of resections has been maximized, leading to an increase of median survival - especially in low-grade gliomas. ⋯ Thus, it seems important that anesthesiologists can benefit from a clear and accurate knowledge of the real contribution of this procedure, in order to better evaluate the balance between the theoretical risks of surgery under local anesthesia versus the actual risk of not performing resection with a maximum of safety and efficiency for the patients. The purpose of this plea is to advocate the spread of awake surgery in routine practice, due to its major impact on both functional and survival outcomes, by nonetheless keeping in mind that a multidisciplinary staff is mandatory for selection of patients as well as into the operating room. In this state of mind, anaesthesiologists have to play a central role, through an increased involvement in this field.