Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2013
ReviewLogistics of transfusion support for patients with massive hemorrhage.
Traditionally, trauma resuscitation protocols have advocated sequential administration of therapeutic components, beginning with crystalloid solutions infused to replace lost intravascular volume. However, rapid restoration of the components of blood is essential for ensuring adequate tissue perfusion and for preventing acidosis, coagulopathy, and hypothermia, referred to as the 'lethal triad' in trauma settings. The review summarizes practical approaches for transfusion support of patients with massive hemorrhage. ⋯ Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions to optimize patients' coagulation, reduce exposure to blood products, and to improve patient outcomes. Future studies are needed to understand and demonstrate improved patient outcomes.
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Curr Opin Anaesthesiol · Apr 2013
ReviewPotential value of protocols in substantially bleeding trauma patients.
Early identification of shock and coagulopathy coupled with damage control resuscitation are central tenets of early trauma management. In traumatic injury, haemorrhage is responsible for almost 50% of deaths occurring within the first 24 h of injury and up to 80% of intraoperative trauma mortalities. Immediate haemorrhagic mortality constitutes the largest group of potentially preventable deaths in the initial 24-h period. This review will discuss the recent changes and advancement of early traumatic coagulopathy and the important role of substantial bleeding protocols (SBPs). ⋯ An SBP addresses the organizational issues necessary to respond to massive blood loss in an immediate and sustained manner. It reduces provider variability, facilitates staff communication and compliance, and simplifies the administration of predefined ratios of blood components. A transfusion subcommittee should be formed to directly address the complex issues of implementing a SBP system.
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Physiotherapy in the perioperative period is emerging as an important component of postoperative recovery. This review highlights recent advances in the implementation of physiotherapy in the perioperative period and its enhancement of postsurgical outcomes. ⋯ Timely and early physiotherapy in the perioperative period improves surgical recovery and reduces postoperative complications.
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Curr Opin Anaesthesiol · Apr 2013
ReviewDo corticosteroids improve outcome for any critical illness?
Corticosteroids have been widely administered in critically ill patients for various indications. Their clinical benefit is broadly investigated but remains controversial. The purpose of this review is to explore the use of corticosteroids in intensive care, their impact on patient outcome and to provide practical guidance for the use of corticosteroids in the ICU. ⋯ Critical illnesses stem from a group of heterogeneous medical conditions. Failure to target subgroups more likely to benefit from the use of corticosteroids may be one explanation for the largely disappointing results in clinical trials, thus, far.
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Curr Opin Anaesthesiol · Apr 2013
ReviewInformed consent for special procedures: electroconvulsive therapy and psychosurgery.
Informed consent has become the cornerstone of the expression of patient's autonomy for ethical and sound patient-physician relationships. However, some severe psychiatric diseases markedly hinder the ability of selected patients to ensure a proper consent. Confronted with mentally disabled individuals whose condition may lead to violence or inflicting it on others, society must carry out its duty of protecting those who are particularly vulnerable, while respecting and protecting these disabled individuals. ⋯ Consent can be relatively easy to secure in selected patients who are often fully aware of their torments (such as those suffering from severe refractory depression of obsessive-compulsive disorders) whose suffering may be such that they are ready to accept, or for that matter demand, such actions. However, the duty of physicians is to realize that pains should always be taken to do as much good (and as little harm) as possible, while respecting the freedom of decision of those who seek to help.