Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Aug 2013
ReviewContinuous renal replacement therapy with regional citrate anticoagulation: do we really know the details?
A significant proportion of critically ill patients with acute kidney injury require continuous renal replacement therapy (CRRT). This article summarizes current evidence on the diagnosis and treatment of acute kidney injury. Regional citrate anticoagulation (RCA) is an emerging but complex technique. A variety of solutions and systems are currently used for RCA. Descriptions of the dosage and methods differ significantly and may cause confusion in everyday practice. This article reviews important scientific findings and highlights pharmacological and pathophysiological aspects of RCA, with a special emphasis on practical clinical issues regarding dosage and available citrate solutions. ⋯ RCA-CRRT is a technique that can be safely used in the majority of intensive care patients with severe multiple-organ failure. The range of citrate solutions available, the different methods in use--continuous venovenous haemofiltration, continuous venovenous haemodialysis and continuous venovenous haemodiafiltration--and the lack of a generally accepted complete CRRT 'set' have impeded implementation of the technique in clinical practice. Unresolved questions regarding dosage and assessment preclude evidence-based comparison in prospective, multicentre studies. For the moment, each institution has to develop a local working protocol. In clinical practice, detailed staff training and monitoring of possible metabolic disturbances for this complex intervention is essential.
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Many studies of new intravenous sedative drugs have been published last year, including several phase I trials. This review provides a brief summary of these studies, with recommendations for selected reading. ⋯ Many of the new sedative drugs were designed to undergo rapid metabolism. Remimazolam has great potential to enter clinical practice because of its rapid offset of action.
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Diabetes mellitus and its related comorbidities present a growing challenge in perioperative medicine. And also largely independent from a history of diabetes, dysregulations of glucose homeostasis occur as part of the body's stress response. Dysregulations of glucose homeostasis, acute or chronic, are closely correlated with impaired prognosis in perioperative medicine. Treatment strategies remain somewhat controversial, as both the affliction and its correction have a blind side. ⋯ Literature clearly shows that leaving glycemic control out of focus is dangerous for the patient; efforts to control glycemia to a moderate target improve the patient's outcome.
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Curr Opin Anaesthesiol · Aug 2013
ReviewStandard approaches for upper extremity nerve blocks with an emphasis on outpatient surgery.
Currently, no standards exist with regard to the techniques and administration of ultrasound-guided peripheral nerve blocks. Consequently, the techniques and teaching substantially vary among practitioners and institutions. The purpose of this review is to propose a set of standard US-guided techniques for upper extremity nerve blocks. ⋯ A set of structured recommendations and approaches are suggested to help standardize clinical practice and teaching of ultrasound-guided upper extremity nerve blocks. Additional emphasis is placed on the discussion of nerve blocks in outpatient surgery.
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Curr Opin Anaesthesiol · Aug 2013
ReviewAnaesthetic considerations for endoscopic retrograde cholangio-pancreatography procedures.
The purpose of this review is to evaluate the current literature on the use of general anaesthesia and propofol deep sedation for patients undergoing endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Propofol is primarily an anaesthetic agent, but its use in a sedative capacity has resulted in the extensive off-label administration of this drug by gastroenterologists and other nonanaesthesia personnel. This has created controversy and enabled the gastroenterology community to gather evidence and campaign for US Food and Drug Administration approval to administer propofol to patients undergoing ERCP and other endoscopic procedures. ⋯ Deep sedation with propofol, administered by anaesthesia personnel, can be used as an alternative to general anaesthesia for a select group of patients undergoing ERCP procedures. Further research is necessary to clarify the nature and parameters of deep sedation.