Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2017
ReviewTherapy of acute kidney injury in the perioperative setting.
The current review analyzes the current pharmacologic approaches in cardiac surgery-associated acute kidney injury and renal replacement/support therapies. ⋯ Cardiac surgery is responsible for the highest risk of renal dysfunction with respect to other surgical settings. A number of different and coacting insults, including toxins, renal hypoperfusion, ischemia-reperfusion injury, and systemic inflammation, are leading causes of this frequent complication. Intense research is ongoing on the treatment of established cardiac surgery-associated acute kidney injury and, in this view, a holistic approach including preoperative data, risk stratification, prevention, timely diagnosis, and aggressive intervention can limit the burdening consequences of renal dysfunction in these patients. Although no specific pharmacologic and nonpharmacologic strategy can be currently recommended outside clinical research, the prompt identification of renal dysfunction and the application of multimodal treatments are fundamental aspects. Right ventricular dysfunction and increased central venous pressure, frequently affecting cardiac surgery patients, potentially lead to congestive renal dysfunction. Hemodynamic management covers a central role in these cases.
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Curr Opin Anaesthesiol · Feb 2017
ReviewSpectrum of postoperative complications in pulmonary hypertension and obesity hypoventilation syndrome.
The purpose of this review is to identify chronic pulmonary conditions which may often not be recognized preoperatively especially before elective noncardiac surgery and which carry the highest risk of perioperative morbidity and mortality. ⋯ Pulmonary hypertension is a well recognized risk factor for postoperative complications after cardiac surgery but the literature surrounding noncardiac surgery is sparse. Pulmonary hypertension was only recently classified as an independent risk factor for postoperative complications in the American Heart Association/American College of Cardiology Foundation Practice Guideline for noncardiac surgery. Spinal anesthesia should be avoided in most surgeries on patients with pulmonary hypertension because of it's rapid sympatholytic effects. The presence of significant right ventricle dysfunction and marked hypoxemia should prompt re-evaluation of the need for elective surgery. Obesity hypoventilation syndrome is even harder to recognize preoperatively as arterial blood gases are generally not obtained prior to elective noncardiac surgery. Amongst patients with obstructive sleep apnea this group of patients carries much higher risk of postoperative respiratory and congestive heart failure.
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Enhanced recovery after surgery (ERAS) methodology has demonstrated consistent benefits in patients undergoing colorectal, urological and thoracic surgeries. Principles of these protocols and their advantages are expected to extend into other surgical specialties such as bariatric surgery. In this review, we summarize the components of ERAS protocols for bariatric surgery and present the evidence on the emerging role of ERAS principles in obese patients. ⋯ ERAS for bariatric surgery is in its early phase. Nevertheless, literature supports its role in improving perioperative outcomes compared with conventional care in this scenario. Evidence-based protocols, multidisciplinary teamwork and meticulous audit seem to be the key factors for success in ERAS methodology.
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Curr Opin Anaesthesiol · Feb 2017
ReviewEpidemiology and pathophysiology of cardiac surgery-associated acute kidney injury.
Acute kidney injury (AKI) remains a serious complication of cardiac surgery. An understanding of the epidemiology and pathophysiology of AKI in cardiac surgery patients is crucial to early recognition and proper management. ⋯ Investigators should aim to use consistent criteria for defining AKI in future studies. Efforts should be taken to use actual measurements rather than estimated values of baseline serum creatinine whenever possible. Further study of the more recently proposed pathophysiologic factors contributing to cardiac surgery-associated AKI, such as circulating damage-associated molecular patterns, venous congestion, and genetic predisposition, are warranted.
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Curr Opin Anaesthesiol · Feb 2017
ReviewAn update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine.
The present review aims to provide an update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine. ⋯ STOP-Bang at least 3 was recommended previously to identify the suspected or undiagnosed OSA. To reduce the false positive cases and to improve its specificity, a stepwise stratification is recommended to identify the patients at high risk of moderate-to-severe OSA. Because of its practical application, STOP-Bang is a useful screening tool for patients with suspected or undiagnosed OSA.