Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2013
ReviewFluid therapy in critical illness: a special focus on indication, the use of hydroxyethyl starch and its different raw materials.
Fluid therapy is a complex intervention with insufficient resuscitation, as well as overinfusion and fluid accumulation being associated with adverse outcomes. Early goal-directed therapy with later conservative fluid management (i.e. prevention of positive fluid balance and weight gain) appears to markedly improve the survival of patients with severe sepsis. The impact of colloids in resuscitation of patients with sepsis has been the topic of several recently published studies. The purpose of the present review is to outline the indication of fluid administration in critically ill patients, discuss the recent findings of trials involving hydroxyethyl starch (HES) solutions and highlight the impact of different raw materials for HES synthesis. ⋯ Adverse effects of fluid resuscitation in critically ill patients appear to be a consequence of dose and timing rather than the type of fluid itself. Modern waxy maize-derived 6% HES 130/0.4 may have advantages over crystalloids in the very early course of the disease. Clinical trials of early, goal-directed and protocolized therapy with innovative endpoints of resuscitation comparing balanced crystalloids and balanced, waxy maize-derived 6% HES 130/0.4 as the initial resuscitation fluid are warranted.
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Curr Opin Anaesthesiol · Jun 2013
ReviewControversies in pediatric anesthesia: sevoflurane and fluid management.
To explore the interrelationships among the pharmacokinetics of sevoflurane, epileptiform electroencephalographic (EEG) activity and awareness in children. To also describe the revised perioperative fluid management strategy espoused by Holliday and Segar and noninvasive measures that may predict who will respond positively to fluid loading. ⋯ Sevoflurane is a well tolerated induction agent that rarely causes seizures in children, but may cause awareness if the inspired concentration is prematurely reduced. Perioperative isotonic fluids should be infused at 20-40 ml/kg over 2-4 h during elective surgery. Noninvasive metrics do not predict a child's responsiveness to fluid loading.
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To keep pediatric anesthesiologists up-to-date in their management of pediatric emergencies by identifying the key publications from 2012 that are relevant to the anesthetic management of common pediatric emergencies. ⋯ Many areas of the management of pediatric emergencies remain controversial and based on little good evidence. In spite of this, the complication rate is low. Postoperative pain is an emerging problem while the optimal management of the full stomach is still unresolved.
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Key elements in the initial resuscitation and stabilization of the patient with sepsis are fluid therapy, vasopressor or inotropic support, administration of adequate antibiotics and source control. This review will primarily discuss fluid, vasopressor and antibiotic therapy because these have been the subject of the recent large clinical trials. ⋯ Recent high-quality trials in the intensive care setting have provided data to improve the treatment and thereby the outcome of patients with sepsis. These findings may be used in the perioperative setting to minimize the harmful effects of specific interventions.
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Although childbirth is considered a natural event, some deliveries may necessitate instrumentation or surgical intervention. In contrast with trauma or surgery, persistent pain after delivery has received little attention until recently, despite the large number of individuals potentially at risk. ⋯ Some recent findings on the development of persistent pain after childbirth are intriguing and might open the way to interesting perspectives for the treatment of persistent pain caused by trauma or surgery.