Current opinion in anaesthesiology
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As clinicians preparing patients for general anesthesia, should we consider the possibility of concussion in our elective operative patients? If so, why is this necessary? Is it possible that exposure to an anesthetic is detrimental to recovery from concussion? If so, what should we do about the imperative/urgency for surgery? No answers are promised in this review. Rather, the focus is on the questions and approaches taken in the recent literature, as well as highlighting a need for more research. ⋯ This review provides a perspective about autonomic nervous system function and cerebrovascular effects of concussion, and some relevant clinical issues that warrant further clinical study.
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Curr Opin Anaesthesiol · Jun 2017
ReviewStrategies to reduce blood product utilization in obstetric practice.
Patient blood management (PBM) aims to improve patient outcome and safety by reducing the number of unnecessary RBC transfusions and vitalizing patient-specific anemia reserves. Although PBM is increasingly recognized as best clinical practice in elective surgery, implementation of PBM is restrained in the setting of obstetrics. This review summarizes recent findings to reduce blood product utilization in obstetric practice. ⋯ Implementation of PBM in obstetric practice offers large potential to reduce blood loss and transfusion requirements of allogeneic blood products, even though large clinical trials are lacking in this specific field. Intravenous iron supplementation may be suggested to increase peripartum hemoglobin levels. Additionally, tranexamic acid and point-of-care-guided supplementation of coagulation factors are potent methods to reduce unnecessary blood loss and blood transfusions in obstetrics.
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The present review highlights recent advances in efforts to improve patient safety on labor and delivery units and well tolerated care for pregnant patients in general. ⋯ A culture of safety is the goal for all obstetric units. Achieving that ideal requires multidisciplinary collaboration, frequent reassessment for areas of improvement, and a culture of openness to change when improvement opportunities arise.
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Curr Opin Anaesthesiol · Jun 2017
ReviewClinical 'pearls' of maternal critical care Part 2: sickle-cell disease in pregnancy.
The current review outlines the challenges in managing pregnant women with sickle-cell anemia, who are at risk of becoming critically ill during pregnancy. ⋯ This is a challenging cohort of pregnant patients who have a significantly increased morbidity and mortality. This review aims to aid management of these patients on the labor ward for both obstetric anesthetists and intensivists.
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Curr Opin Anaesthesiol · Jun 2017
ReviewPrevention of respiratory complications of the surgical patient: actionable plan for continued process improvement.
Postoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common. ⋯ Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.