Current opinion in anaesthesiology
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Liver failure is a rare but life-threatening condition affecting a multitude of other organ systems, most notably the brain and kidneys, following severe hepatocellular injury. Liver failure may develop in the absence ('acute') or presence ('acute-on-chronic') of liver disease with substantial differences in pathophysiology and therapeutic options. Within the last 12 months substantial progress has been made in identifying patients who will potentially benefit from extracorporeal support of their failing liver. ⋯ Although mortality remains high, substantial progress has been made in 2004 regarding the understanding of pathophysiology, and the monitoring and support of the patient presenting with a failing liver.
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Changes in epidemiology and advances in the treatment of coronary artery disease, hypertension and diabetes mellitus have increased the prevalence of heart failure in the general population, and also the number of patients with heart failure presenting for surgery. Particularly in the perioperative period, patients with chronic heart failure are faced with numerous triggers of acute decompensation that can partly be avoided or treated. Patients without preexisting myocardial contractile dysfunction may sustain severe perioperative complications, e.g. myocardial infarction, with subsequent acute heart failure as a consequence. Approaches for diagnosis and treatment in these situations may vary considerably. ⋯ The role of B-type natriuretic peptide testing in the perioperative period is confounded by several variables that limit its use in that setting. New developments in positive inotropic therapy are challenging older and potentially harmful treatment strategies.
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This paper aims to provide a condensed review of the most essential and current research findings in the field of acute lung injury over the past year. ⋯ Recent advances in our understanding of the pathogenesis of acute lung injury have provided the promise of exciting potential interventions to modify intravascular and extravascular fibrinogenesis, neutrophil activation and clearance, and alveolar fluid clearance. Our new understanding of prolonged disability and post-traumatic stress in acute lung injury survivors will ultimately change the standard for how these patients are managed in the intensive care unit and followed beyond their hospital stay.
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Perioperative hypothermia triples the incidence of adverse myocardial outcomes in high-risk patients; it significantly increases blood loss and augments allogeneic transfusion requirements. Even mild hypothermia increases the incidence of surgical wound infection following colon resection and therefore the duration of hospitalization. Hypothermia adversely affects antibody- and cell-mediated immune defenses, as well as the oxygen availability in the peripheral wound tissues. Mild perioperative hypothermia changes the kinetics and action of various anesthetic and paralyzing agents, increases thermal discomfort, and is associated with delayed postanesthetic recovery. ⋯ This article reviews recent publications in the field of accidental as well as therapeutic hypothermia, and tries to assess what evidence is available at the present time.
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Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. This update reviews recent publications related to pain relief in the trauma patient. ⋯ Educating the emergency room staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma. Peripheral nerve block techniques should be practised by emergency room staff. If simple techniques are chosen, competence can be achieved with short, focused training sessions. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient.