Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2006
ReviewSome current controversies in paediatric regional anaesthesia.
Controversial topics in paediatric regional anaesthesia are discussed. ⋯ The performance of regional blocks in anaesthetized patients is generally contra-indicated in adults but accepted in children. Levobupivacaine displays the same pharmacokinetic profile as racemic bupivacaine with possibly less cardiac toxicity. Ropivacaine undergoes slower absorption and, in some studies, concomitant increase in peak plasma concentration in infants. Conversely, continuous infusion of ropivacaine offers the safest therapeutic index. Many adjuvants have been used but only epinephrine, clonidine, and preservative-free ketamine offer clear advantages. Midazolam and neostigmine are effective but have potential drawbacks and raise safety questions. Needle and catheter positioning is critical. Electrocardiogram guidance and electrical stimulation occasionally help identify the migration of epidural catheters. Stimulating catheters might be useful for continuous peripheral blockade. Ultrasonography will probably become the reference technique for peripheral catheter placement. Patients at risk of compartment syndrome must be monitored (measurement of compartmental pressures); adequate pain management does not 'hide' this complication but, on the contrary, can facilitate early diagnosis since the increase in requirement for pain medication precedes other clinical symptoms by an average of 7.3 h.
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This review summarizes the current progress in disease classification, pathophysiology and management of diabetes mellitus with a special focus on treatment modalities and recommendations for the practicing anesthesiologist. ⋯ According to World Health Organization projections, anesthesiologists can expect to care for more diabetic patients than ever before. Diabetes and its associated complications present unique challenges to the perioperative physician. As biomedical research continues to unravel the genetic, cellular and molecular mechanisms of this complex metabolic disease, our specialty must be prominently involved in the design and testing of innovative treatments to protect the diabetic patient from the risks of surgery and anesthesia.
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Curr Opin Anaesthesiol · Apr 2006
ReviewFactors affecting supply and demand of anesthesiologists in Western Europe.
Current demographic and macroeconomic trends indicate that, in Western Europe, the demand for anesthesia services will continue to increase. It is, however, questionable whether there will be sufficient supply. ⋯ Steps must be taken to augment the number of practitioners to ensure a sufficient number of anesthesiologists. Employers will have to offer flexible working practices and adequate compensation to attract new anesthesiologists. Alternatively, more responsibilities and tasks may be allocated to well-trained anesthesia assistants (e.g. nurses). National anesthesia associations must improve and coordinate resident training, which may alleviate the recruitment problem. A European training standard in anesthesia might adjust the regional disequilibrium of supply and demand, as might salary competition. In the long run, the undersupply of anesthesiologists may be offset by factors such as more procedures being performed non-invasively and further demand-lowering healthcare policies.
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Curr Opin Anaesthesiol · Apr 2006
ReviewNutrients with immune-modulating effects: what role should they play in the intensive care unit?
This review will summarize recent clinical and experimental data on the use of immune-modulating nutrients in critical illness. It will present the concept of these nutrients as pharmacologic agents or 'nutraceuticals' administered in addition to protein, calorie, vitamin, and trace element sources. ⋯ Cumulative studies of enteral immune-modulating nutritional formulations report benefits in surgical critically ill patients such as burn, trauma, or gastrointestinal surgery populations. Conflicting data in patients with sepsis warrant concern and further evaluation; in particular, controversy seems to stem around the use of arginine. Glutamine is beneficial when given in high doses or via the parenteral route (>0.20-0.30 g/kg per day or >or=30 g/day). Providing both omega-3 and omega-6 polyunsaturated fatty acids is important in immune modulation. The best doses and combinations of immune-modulating components remain unclear.
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Hyperglycemia occurs commonly among acutely ill patients owing to a combination of counterregulatory and stress responses, as well as insulin resistance and deficiency, and is associated with increased morbidity and mortality in a variety of different patient populations. This manuscript reviews the adverse consequences of hyperglycemia in these different settings and focuses on perioperative glycemic management. ⋯ Hyperglycemia is associated with adverse outcomes in acutely ill adult patients and its treatment has been shown to improve mortality and morbidity in a variety of different settings. Additional studies are needed in heterogeneous populations of critically ill patients as well as in other populations of acutely ill patients, especially general surgical patients, to confirm the early studies and define the correct glycemic target.