Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2009
ReviewAnesthesia in adult patients with congenital heart disease.
Recent advances in prenatal diagnosis, interventional cardiology, pediatric cardiac surgery, anesthesia, and critical care have resulted in an increasing number of adult patients with congenital heart disease (CHD). Most of these patients will require noncardiac surgery thus presenting a new challenge for anesthesiologists. The purpose of this article is to summarize preoperative and intraoperative implications for the anesthesiologist in the noncardiac surgery setting. ⋯ The number of adult patients with CHD is now superior to the number of children. This is a new challenge for anesthesiologist in the noncardiac surgery settings.
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Curr Opin Anaesthesiol · Feb 2009
ReviewUpdate on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation--clinical application.
The purpose of this review is to examine the evidence for and the clinical use of continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) for the management of one-lung ventilation during thoracic surgery. CPAP and PEEP use are important as we are increasingly challenged with patients with less respiratory reserve and greater comorbidity leading to the need for greater clinical management and more interventions during one-lung ventilation for thoracic surgery to prevent perioperative complications. ⋯ CPAP and PEEP are useful not only to treat hypoxia and atelectasis as the consequence of one-lung ventilation, perhaps more importantly, also as part of a protective lung-ventilation strategy to ameliorate mechanical stress and prevent acute lung injury.
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The nonspecific protease inhibitor aprotinin has been used successfully to reduce bleeding in cardiac surgery. Recent investigations have questioned its safety, and aprotinin has finally been withdrawn from marketing after a large prospective study demonstrated a trend toward higher mortality. ⋯ It remains a matter of speculation whether the quality and results of published data justify the withdrawal of aprotinin; however, one has to accept that this drug is no longer available. It is clear from the aprotinin story that there are no effective instruments to control the safety and clinical efficacy of a drug after its regulatory approval. This highlights the urgent need for independent clinical safety studies after the formal registration of a drug.
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Curr Opin Anaesthesiol · Feb 2009
ReviewPostoperative care after pulmonary resection: postanesthesia care unit versus intensive care unit.
In an effort to maximize resource utilization and contain costs, immediate postoperative care after noncardiac thoracic surgery is often done in either the postanesthesia care unit or dedicated step down units, leaving the ICU for complex surgical cases, overtly high-risk patients, or the treatment of severe postoperative complications. This review analyzes the current modalities affecting length of stay and costs, mainly by allocating patients after elective lung resection to different postoperative areas according to their needs. ⋯ The development of models to help predict elective ICU admission should facilitate optimal care, cutting costs and shortening length of stay after lung resection.
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Curr Opin Anaesthesiol · Feb 2009
ReviewUpdate on the role of paravertebral blocks for thoracic surgery: are they worth it?
To consider optimal analgesic strategies for thoracic surgical patients. ⋯ There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.