Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2017
ReviewCriteria for Intensive Care admission and monitoring after elective craniotomy.
The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy. ⋯ After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring.
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The aim of this review is to examine data relating to perioperative management of the patient with neuromuscular disorders RECENT FINDINGS: Patients with pre-existing neuromuscular disorders are at risk for a number of postoperative complications that are related to anesthetic drugs that are administered intraoperatively. Careful preoperative assessment is necessary to reduce morbidity and mortality. In particular, the risk of postoperative respiratory failure and need for long-term ventilation should be reviewed with patients. The use of succinylcholine should be avoided in muscular dystrophies, motor neuron diseases, and intrinsic muscle disease due to a risk of malignant hyperthermia, hyperkalemia, rhabdomyolysis, and cardiac arrest. The use of quantitative neuromuscular monitoring should be strongly considered whenever nondepolarizing neuromuscular blocking agents are administered. A number of case series and reports have been recently published demonstrating that sugammadex can be safely used in patients with neuromuscular disease; the risk of residual neuromuscular is nearly eliminated when this agent is administered intraoperatively. ⋯ Careful assessment and management of patients with underlying neuromuscular diseases is required to reduce postoperative complications. This article reviews the anesthetic implications of patients undergoing surgery with neuromuscular disorder.
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Low-dose hydrocortisone is recommended in patients with septic shock unresponsive to fluid and vasopressor therapy. Recent research added new data for patients with septic shock and other target groups such as patients with severe sepsis, acute respiratory distress syndrome (ARDS), community-acquired pneumonia, and burns. The objective of this review is to summarize and comment recent findings on low-dose corticosteroids (LDC) in critically ill patients. ⋯ Low-dose hydrocortisone or a corresponding low-dose corticosteroid therapy may improve morbidity in specific target groups of critically ill patients. Beneficial effects on mortality remain to be demonstrated in large-scale randomized controlled trials.
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Curr Opin Anaesthesiol · Oct 2017
ReviewAcupuncture for chronic pain: an update and critical overview.
Acupuncture is now recommended for several chronic pain conditions. Despite supportive evidence of its effectiveness, this ancient approach is often misunderstood, and may still be underused in mainstream practice. A critical review on its effectiveness and practice integration, and mechanisms of action is essential to the medical community that is continuing to seek nonopioid therapies for chronic pain. ⋯ Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. Further studies on its use as an adjunct or alternative to opioids, and in perioperative settings are needed.
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To summarize recent relevant studies regarding nutrition during critical illness and provide recommendations for clinical practice. ⋯ Body composition especially lean body mass is associated with clinical outcomes. The modified NUTrition Risk in the Critically ill score was validated for nutritional risk assessment and identifies patients that benefit from higher nutritional intake; however, caloric restriction decreases mortality in refeeding syndrome. Gastric residual volume monitoring is debated, as abandoning its application doesn't worsen outcome. There is no consensus regarding benefits of gastric vs postpyloric tube placement. Current prokinetics temporarily reduce feeding intolerance, new prokinetics are developed. Enteral remains preferable over parenteral nutrition, although no inferiority of parenteral nutrition is reported in recent studies. Studies imply no harm of hypocaloric feeding when protein requirements are met. Optimal protein provision may be more important than caloric adequacy. Pharmaconutrition confers no superior outcomes and may even confer harm. Dysbiosis is frequently encountered and associated with worse outcomes. Probiotics reduce infectious complications, but not mortality, and may contribute to earlier recovery of gut function.