Current opinion in anaesthesiology
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Fluid resuscitation in trauma patients with hemorrhagic shock is controversially discussed in the literature. The coincidence of brain injury complicates management of these patients. This article summarizes the current knowledge on nonblood component fluid resuscitation and choice of fluids in patients with multiple trauma. ⋯ To date no large-scale clinical studies exist to either support or refute the use of nonblood component fluid resuscitation of hemorrhagic shock in trauma patients. The optimal choice of fluid remains to be determined, but existing evidence suggests avoiding crystalloids in favor of hypertonic solutions. The role of modern, iso-oncotic colloids in the treatment of hemorrhagic shock has not yet been sufficiently defined. In patients with concomitant brain injury, arterial hypotension must be avoided and infusion of hypotonic solutions is obsolete, whereas administration of hypertonic solutions may exert beneficial effects beyond hemodynamic stabilization.
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Curr Opin Anaesthesiol · Apr 2011
ReviewIntracranial pressure: why we monitor it, how to monitor it, what to do with the number and what's the future?
The review touches upon the current physiopathological concepts relating to the field of intracranial pressure (ICP) monitoring and offers an up-to-date overview of the ICP monitoring technologies and of the signal-analysis techniques relevant to clinical practice. ⋯ Current recommendations for the management of traumatic brain injury indicate ICP monitoring in patients who remain comatose after resuscitation if the admission computed tomography scan reveals intracranial abnormalities such as haematomas, contusions and cerebral oedema. The most reliable methods of ICP monitoring are ventricular catheters and intraparenchymal systems. A growing number of these devices are being safely placed by neurointensivists. The consensus is to treat ICP exceeding the 20 mmHg threshold, and to target cerebral perfusion pressure between 50 and 70 mmHg. Recent evidence suggests that such thresholds should be optimized based on multimodality monitoring and individual brain physiology. Noninvasive ICP estimation using transcranial Doppler can have a role as a screening tool in patients with low to intermediate risk of developing intracranial hypertension. However, the technology remains insufficiently accurate and too cumbersome for continuous ICP monitoring.
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In the current era of limited resources, organizations are evaluating the cost-effectiveness of their care. To analyze the cost-effectiveness of a physiologic monitor, one must first determine what negative outcome will be reduced or what positive outcome will be promoted. For example, if one was studying the cost-effectiveness of the pulse oximeter, it would be important to state whether the endpoint is prevention of hypoxic events or prevention of myocardial infarction. One would then need outcome data demonstrating the incidence of the chosen endpoint with and without the monitor. With these data, one can begin to construct a model for cost-effectiveness. Like many medical technologies, the bispectral index (BIS) monitor has recently been the subject of several articles which study its cost-effectiveness. This review examines the rationale of cost-effectiveness analyses and their application specifically to the BIS monitor. ⋯ Given the trivial cost of the BIS and the proven benefits demonstrated in prospective randomized studies, we consider its use justified in every general anesthetic.
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Curr Opin Anaesthesiol · Apr 2011
ReviewPublication fraud: implications to the individual and to the specialty.
To provide a brief review and update on the subject of scientific misconduct relevant to the specialty of anesthesia. The overall goal is to raise awareness amongst readers of the scientific literature that although publication fraud is relatively infrequent, the reasons for fraud are complex and the consequences to the individual and for the specialty are substantial. ⋯ When suspected, alleged misconduct must be thoroughly investigated. When proven, scientific misconduct must be addressed by the relevant institutions and the scientific record must be corrected. Many stakeholders are involved in this complex and most unfortunate process.
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It has become clear from experimental data that prolonged mechanical ventilation can induce diaphragm dysfunction, also known as ventilator-induced diaphragm dysfunction. In this article we will discuss most recent understanding on ventilator-induced diaphragm dysfunction and data on diaphragm dysfunction in patients. ⋯ Diaphragm dysfunction occurs in patients, especially when ventilated with controlled modes of ventilation that minimize diaphragm activity. Time on the ventilator seems to be one of the biggest risk factors resulting in difficulties in weaning patients and prolonging time on the ventilator. Future trials should investigate whether improved patient-ventilator synchrony can reduce ventilator-induced diaphragm dysfunction and decrease weaning failure.