Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2017
Improving outcome of trauma patients by implementing patient blood management.
Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. ⋯ In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs.
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Curr Opin Anaesthesiol · Apr 2017
ReviewHemotherapy algorithm for the management of trauma-induced coagulopathy: the German and European perspective.
This review presents a synopsis of best current knowledge with reference to the updated German and European guidelines and recommendations on the management of severe trauma hemorrhage and trauma-induced coagulopathy as well as a viscoelastic-based treatment algorithm based upon international expert consensus to trigger the administration of hemostatic agents and blood products. ⋯ Current guidelines urge for the implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome.
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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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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.
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Curr Opin Anaesthesiol · Apr 2017
ReviewEvolving healthcare delivery paradigms and the optimization of 'value' in anesthesiology.
Healthcare worldwide is evolving to yield enhanced care provided at a lowered cost. Patient-centric paradigms that hasten surgical recovery and strengthen collaboration amongst medical professionals are gaining impetus. This review will discuss the changing healthcare landscape and outline its implications on anesthesiology practice. ⋯ Exemplifying opportunities to demonstrate value-added care, the scope of anesthesiology education and clinical practice should diversify to further integrate perioperative care of surgical patients.