Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2009
ReviewThe role of recombinant-activated factor VII in bleeding trauma patients.
Exsanguinating hemorrhage and postshock organ failure account for 35-40% of deaths from trauma, and there is an increasing recognition of the importance of coagulopathy in the evolution of this disease. ⋯ We present a brief discussion of the mechanism of action of rFVIIa and its role in facilitating hemostasis and a review of the recent medical literature on the use of rFVIIa in trauma patients, including current guidelines and controversies.
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Coagulopathy represents one of the major challenges in the management of the severely injured patient. The present review will attempt to define the current 'optimal' transfusion strategies for the coagulopathic trauma patient and to assess potential weaknesses in the pertinent literature. ⋯ Coagulopathy has a significant impact on survival after major trauma. Most recent publications in the field are of retrospective design, and thus do not allow definitive recommendations for clinical practice. Well designed prospective trials and improved basic research studies are required to improve this important aspect of trauma care.
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Curr Opin Anaesthesiol · Apr 2009
ReviewMicrocirculatory effects of intravenous fluids in critical illness: plasma expansion beyond crystalloids and colloids.
Plasma expanders are reviewed to determine their ability to restore microvascular function as a means for extending the transfusion trigger and delaying the use of blood transfusions. This outcome is currently achievable because of the emergence of a new understanding of optimal tissue function that prioritizes maintenance of functional capillary density, which results from the normalization of blood viscosity via the increase in plasma viscosity with new viscogenic colloids. ⋯ Preclinical studies show that polyethylene glycol-conjugated albumin at concentrations in the range of 2-4% extends the transfusion trigger, providing the more extended and complete microvascular and systemic recovery from hemorrhagic shock, extreme hemodilution and endotoxemia, postponing the need of reestablish intrinsic blood oxygen-carrying capacity to hemoglobin concentrations lower than those associated with accepted transfusion triggers.
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To provide a practical approach to measure and then improve the quality of an academic anesthesia department. ⋯ Departments of anesthesia should develop performance criteria in multiple domains and recognize the importance of human relationships (between staff and between staff and patients) in quality and safety. To improve the value of anesthesia services, departments should identify their user groups, survey them to determine what attributes are important to the user, then deliver, measure, monitor and improve them on an ongoing basis.
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Curr Opin Anaesthesiol · Apr 2009
ReviewMicrocirculation and mitochondria in sepsis: getting out of breath.
To present the recent findings obtained in clinical and experimental studies examining microcirculatory alterations in sepsis, their link to mitochondrial dysfunction, and current knowledge regarding the impact of these alterations on the outcome of septic patients. ⋯ Even though there is evidence that microcirculatory and mitochondrial dysfunction plays a role in the development of sepsis-induced organ failure, their interaction and respective contribution to the disease remains poorly understood. Future research is necessary to better define such relationships in order to identify therapeutic targets and refine treatment strategies.