Current opinion in anaesthesiology
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The nonspecific protease inhibitor aprotinin has been used successfully to reduce bleeding in cardiac surgery. Recent investigations have questioned its safety, and aprotinin has finally been withdrawn from marketing after a large prospective study demonstrated a trend toward higher mortality. ⋯ It remains a matter of speculation whether the quality and results of published data justify the withdrawal of aprotinin; however, one has to accept that this drug is no longer available. It is clear from the aprotinin story that there are no effective instruments to control the safety and clinical efficacy of a drug after its regulatory approval. This highlights the urgent need for independent clinical safety studies after the formal registration of a drug.
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Curr Opin Anaesthesiol · Feb 2009
ReviewUpdate on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia.
This review is focused on tracheobronchial anatomy and the use of flexible fiberoptic bronchoscopy in thoracic anesthesia. ⋯ Recognition of tracheobronchial anatomy and familiarity with the use of flexible fiberoptic bronchoscope are key components while managing patients undergoing thoracic surgery and anesthesia.
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Interventional pulmonology is a rapidly expanding field offering less invasive therapeutic procedures for significant pulmonary problems. Many of the therapies may be new for the anesthesiologist. Although less invasive than surgery, some of these procedures will carry significant risks and complications. The team approach by anesthesiologist and pulmonologist is key to the success of these procedures. ⋯ This review is intended to familiarize the anesthesiologist with current and rising therapeutic modalities for pulmonary disease. Knowledge of interventional pulmonology facilitates planning and preparation for well tolerated and effective procedures.
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The primary goal of hemodynamic therapy is the prevention of inadequate tissue perfusion and inadequate oxygenation. Advanced cardiovascular monitoring is a prerequisite to optimize hemodynamic treatment in critically ill patients prone to cardiocirculatory failure. The most ideal cardiac output (CO) monitor should be reliable, continuous, noninvasive, operator-independent and cost-effective and should have a fast response time. Moreover, simultaneous measurement of cardiac preload enables the diagnosis of hypovolemia and hypervolemia. ⋯ Minor invasive arterial thermodilution is the standard for the estimation of CO. Less invasive and continuous techniques such as pulse-contour CO and arterial waveform analysis are preferable. The accuracy of noncalibrated pulse-contour analysis is still a matter of discussion, although recent studies demonstrate acceptable accuracy compared with a standard technique. Doppler techniques are minimally invasive and offer a reasonable trend monitoring of CO. Noninvasive continuous techniques such as bioimpedance and bioreactance require further investigation.
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Curr Opin Anaesthesiol · Feb 2009
ReviewOpen or minimally invasive esophagectomy: are the outcomes different?
Since the beginning of the 1990s, the use of minimally invasive esophagectomy instead of the open technique has increased. Should this type of approach change the way we manage anesthesia for a patient undergoing esophagectomy for cancer? ⋯ The implantation of minimally invasive esophagectomy seems inevitable in spite of the absence of randomized, controlled trials. The use of the prone position with one lung ventilation during minimally invasive esophagectomy seems positive. Protective ventilation during one lung ventilation may help to prevent pulmonary complications. Finally, the well accepted use of thoracic epidural anesthesia now has a new positive role following esophagectomy, improving the perfusion at the anastomotic level.