Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2023
ReviewCurrent hemoglobin thresholds in pediatric anesthesia - guidelines and studies.
The use of restrictive transfusion triggers to avoid unnecessary transfusions is one important pillar of Patient Blood Management (PBM). For the safe application of this principle in pediatric patients, anesthesiologists need evidence-based guidelines for hemoglobin (Hb) transfusions thresholds in this specially vulnerable age-group. ⋯ Two high-quality studies confirmed that the use of restrictive transfusion triggers in preterm infants in the intensive care unit (ICU) is reasonable and feasible. Unfortunately, no recent prospective study could be found investigating intraoperative transfusion triggers. Some observational studies showed wide variability in Hb levels before transfusion, a tendency toward restrictive transfusion practices in preterm infants, and liberal transfusion practices in older infants. Although there are comprehensive and useful guidelines for clinical practice in pediatric transfusion, most of them do not cover the intraoperative period in particular because of a lack of high-quality studies. This lack of prospective randomized trials focusing on intraoperative transfusion management remains a major problem for the application of pediatric PBM.
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Curr Opin Anaesthesiol · Jun 2023
ReviewCurrent concepts in preoperative anemia management in obstetrics.
The purpose of this article is to provide an overview of currently recommended treatment approaches for anemia during pregnancy, with a special focus on iron deficiency and iron deficiency anemia (IDA). ⋯ The treatment of anemia, and more specifically iron deficiency anemia during pregnancy, holds many possibilities for improvement. The fact that the period of risk is known well in advance and thus there is a long optimization phase is per se an ideal prerequisite for the best possible therapy of treatable causes of anemia. Standardization of recommendations and guidelines for screening and treatment of IDA in obstetrics is required for the future. In any case, a multidisciplinary consent is the precondition for a successfully implementation of anemia management in obstetrics to establish an approved algorithm easily enabling detection and treatment of IDA during pregnancy.
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Curr Opin Anaesthesiol · Jun 2023
ReviewAnesthetic management of patients with peripartum cardiomyopathy.
Cardiovascular disease is increasingly emerging as a cause of peripartum morbidity and mortality. Peripartum cardiomyopathy (PPCM) is defined as pregnancy-related heart failure with a reduced left ventricular ejection fraction <45%. PPCM develops in the peripartum phase and is not an aggravation of an existing prepregnancy cardiomyopathy. Anesthesiologists typically encounter these patients in the peripartum phase in a variety of settings and should be aware of this pathology and its implications for the perioperative management of parturients. ⋯ Although PPCM is an overall rare pathology, patients can potentially be encountered by any anesthesiologist in many different settings. Therefore, it is important to be aware of this disease and understand the basic implications for anesthetic management. Severe cases often require early referral to specialized centers for advanced hemodynamic monitoring and pharmacological or mechanical circulatory support.
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Curr Opin Anaesthesiol · Jun 2023
ReviewCoagulation management and transfusion in massive postpartum hemorrhage.
Excessive bleeding during and following childbirth remains one of the leading causes of maternal mortality. ⋯ Factor deficiency is uncommon at the beginning of most etiologies of PPH but will eventually develop from consumption and depletion in the absence of bleeding control. The sensitivity of point-of-care tests for fibrinolysis is too low and may delay treatment, therefore tranexamic acid should be started early at diagnosis even without signs for hyperfibrinolysis. Transfusion management may be initiated empirically, but is best to be guided by laboratory and viscoelastic assay results as soon as possible. Hypofibrinogenemia is well detected by point-of-care tests, thus substitution may be tailored to individual needs, while reliable thresholds for fresh frozen plasma (FFP) and specific components are yet to be defined. In case of factor deficiency, prothrombin complex concentrate or lyophilized plasma allow for a more rapid restoration of coagulation than FFP. If bleeding and hemostasis are under control, a timely anticoagulation may be necessary.
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Curr Opin Anaesthesiol · Jun 2023
ReviewAnaesthesia and cancer recurrence: the influence of perioperative anaesthetic technique on cancer recurrence after surgery.
Cancer is a leading cause of death worldwide, and incidence is increasing. Excisional surgery is essential in approximately 70% of solid organ tumours. Emerging research in onco-anaesthesiology suggests that perioperative anaesthetic and analgesic techniques might influence long-term oncologic outcomes. ⋯ Although regional anaesthesia definitively does not affect cancer recurrence, ongoing prospective RCTs with oncological outcomes as primary endpoints are awaited to establish if other anaesthetic or analgesic techniques influence cancer recurrence. Until such trials conclusively identify a causal relationship, insufficient evidence exists to recommend specific anaesthetic or analgesic techniques for tumour resection surgery based on altering the patient's risk of recurrence.