Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2012
ReviewPreoperative optimization: rationale and process: is it economic sense?
The development of preoperative clinics and the increasing importance of the anaesthetist in the management of surgical risk have expanded the concept of preoperative optimization. This review will focus on the rationale and process for cost-effective preoperative optimization. ⋯ The requirement for appropriate methods of risk stratification of surgical patients targeted at the reduction of postoperative morbidity, underpins the development of cost-effective preoperative optimization. Specific process-based and clinical measures may then be applied to the development of individualized perioperative care packages.
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Conventional wisdom maintains that multiple aspects of surgical technique and management may affect postoperative outcome, while anaesthetic technique has little long-term effect on patient outcomes. There is accumulating evidence that, on the contrary, anaesthetic management may in fact exert a number of longer-term effects in postoperative outcome. Here, we review the most topical aspects of anaesthetic management which may potentially influence later postoperative outcomes. ⋯ Further prospective, large-scale human trials with long-term follow-up are required to clarify the association between anaesthesia and cancer recurrence, neurotoxicity and the developing brain and long-term postoperative cognitive dysfunction in the elderly.
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Recent therapeutic and observational studies have demonstrated improved survival with better management of haemostasis early after injury. This review delineates our current understanding of the clinical importance, aetiology and pathophysiology of acute traumatic coagulopathy (ATC). ⋯ Conventional concepts of traumatic coagulopathy as a late occurring condition in response to iatrogenic haemodilution are redundant. ATC is an endogenous impairment of haemostasis that begins at the moment of injury. Further outcome improvements are possible with better understanding of the process by which this coagulopathy develops and how it may be inhibited.
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Curr Opin Anaesthesiol · Apr 2012
ReviewCoagulation monitoring of the bleeding traumatized patient.
Death due to trauma is the leading cause of lost life years worldwide, with haemorrhage being responsible for 30-40% of trauma mortality and accounting for almost 50% of the deaths in the initial 24 h. On admission, 25-35% of trauma patients present with coagulopathy, which is associated with a several-fold increase in morbidity and mortality. ⋯ This article reviews the basic principles of VHA, the correlation between the VHA whole blood clot formation in accordance with the cell-based model of haemostasis, the current use of VHA-guided therapy in trauma and limitations of VHA.
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Curr Opin Anaesthesiol · Apr 2012
ReviewUltrasound-guided peripheral nerve blockade of the upper extremity.
Is ultrasound guidance changing the practice of upper extremity regional anesthesia? This review will aim to describe the findings published in the literature during the previous 18 months. ⋯ Current literature suggests a reduction of the volume of local anesthetics used for ultrasound-guided upper extremity blockades. Dexamethasone may prolong duration of brachial plexus blocks and more frequent use of perineural catheters is encouraged. Controversy over intra-epineurial injections exists and requires additional large-scale studies.