Current opinion in anaesthesiology
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Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy (TIC) have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the role of fibrinogen in normal haemostasis, the effect of trauma and TIC on fibrinogen levels and current evidence for fibrinogen replacement in the management of traumatic haemorrhage. ⋯ The important role fibrinogen plays in haemostasis and effective clot formation is clear. A number of pilot trials have investigated different strategies for fibrinogen replacement in severe trauma. These trials have formed the basis of several large-scale phase III trials, which, cumulatively will provide a firm evidence base to harmonise worldwide clinical management of severely injured trauma patients with major haemorrhage.
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Curr Opin Anaesthesiol · Aug 2021
ReviewSelective periarticular blocks for postoperative pain after hip and knee arthroplasty.
This review aims to provide an overview of selective periarticular blocks for postoperative pain after hip and knee arthroplasty and the current evidence for their use. ⋯ The pericapsular blocks of the hip (pericapsular nerve group block, iliopsoas plane block, hip block), genicular nerves block, and infiltration between the popliteal artery and the capsule of the knee play an increasingly important role in providing postoperative analgesia after hip and knee arthroplasty without impeding fast-track protocols.
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Curr Opin Anaesthesiol · Aug 2021
ReviewGetting hit by the bus around the world - a global perspective on goal directed treatment of massive hemorrhage in trauma.
Major trauma remains one of the leading causes of death worldwide with traumatic brain injury and uncontrolled traumatic bleeding as the main determinants of fatal outcome. Interestingly, the therapeutic approach to trauma-associated bleeding and coagulopathy shows differences between geographic regions, that are reflected in different guidelines and protocols. ⋯ There are multiple coexistent treatment standards for trauma-induced coagulopathy in different countries and different trauma centers. Most of them initially follow a protocol-based approach and subsequently focus on predefined clinical and laboratory targets.
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Curr Opin Anaesthesiol · Aug 2021
ReviewPatient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology.
Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring. ⋯ NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.
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Severe bleeding events, which require blood transfusions, are a challenge faced by many critical care physicians on a daily basis. Current transfusion guidelines generally recommend rather strict transfusion thresholds and strategies, which can appear opposing to a patient in need for urgent transfusion at first sight. Moreover, applied guidelines are lacking evidence and specificity for the typical ICU patient population and its comorbidities. Transfusion decisions, which are pivotal for clinical outcome, are often unsatisfactorily based on hemoglobin levels only. ⋯ The body of evidence for ICU-specific transfusion guidelines is scarce. Critical care physicians should properly evaluate their patient's comorbidities and consider extended point-of-care testing for transfusion decisions in indistinct anemic situations. A strict transfusion strategy should, however, be applied whenever possible.