Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2018
ReviewRole of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?
Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. ⋯ Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.
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Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences. ⋯ Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.
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Curr Opin Anaesthesiol · Apr 2018
ReviewThe ethics of interventional procedures for patients too ill for surgery.
Minimally invasive interventional procedures are increasingly popular options for patients who are high-risk candidates for open surgical procedures. It is unclear how to proceed in the rare circumstance of a complication during an interventional procedure, where addressing the complication would require exposing the patient to the full risk that was being avoided with the minimally invasive technique. This review provides recommendations on how to approach this paradoxical scenario. ⋯ Interventional procedures, and emergent open surgery, should be offered as long as patients are fully informed about the benefits and risks, including the implications of potential life-sustaining treatments, and whether their respective goals of treatment are consistent with the intervention. Implementing this framework will require a cultural shift in physician attitudes to recognize that in some cases, nonintervention or less aggressive treatment may be a reasonable alternative to surgical intervention.
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Deep vein thrombosis (DVT) and pulmonary embolus are major causes of hospital-related morbidity and mortality, and are recognized as complications in patients with traumatic injury. Despite the significant morbidity and mortality associated with DVTs, prophylaxis and treatment are still not well understood and remain the subject of research and debate. ⋯ In trauma patients with traumatic injury, early identification and targeted VTE prophylaxis in trauma patients may prevent this life-threatening complication.
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Curr Opin Anaesthesiol · Apr 2018
ReviewFibrinolysis and antifibrinolytic treatment in the trauma patient.
The role of antifibrinolytics in trauma haemorrhage and early coagulopathy remains controversial with respect to patient selection, dosage, timing of treatment, and risk of thrombotic complications. This review presents our current understanding of the mechanisms of fibrinolysis in trauma, diagnostic evaluation, and the evidence base for treatment. ⋯ Improving the outcomes for bleeding trauma patients requires a deeper understanding of the mechanisms driving hyperfibrinolysis and the subsequent switch toward a prothrombotic state. Discovering the interplay between platelet activity, fibrinogen utilization, the immune response, and the fibrinolytic system may lead to development of novel therapeutics.