Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2008
ReviewA logical approach to the selection and insertion of double-lumen tubes.
There has been a progressive evolution in double-lumen tubes to separate the right and left lungs. The appreciation of the anatomical advantage of the longer left main bronchus has directed anesthetists to prefer a left tube if possible for lung separation. Understanding the dimensions of the tube as well as the variations in the left main bronchus has improved the process of selection and insertion of the double-lumen tubes for lung isolation. ⋯ Measurement of patient's airway dimensions combined with knowledge of the dimensions of the double-lumen (tracheobronchial) tube plays an important role in lung separation.
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Curr Opin Anaesthesiol · Feb 2008
ReviewAnesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma.
Extrapleural pneumonectomy is a radical and aggressive surgery that presents a great challenge to the thoracic anesthesiologist. This surgery is performed routinely by only a few centers in the world and this review represents our institution's experience in anesthetic care. ⋯ Anesthetic management importantly contributes to containment of the perioperative complications of extrapleural pneumonectomy. An appreciation of the technical aspects and physiologic disruptions associated with extrapleural pneumonectomy is critical to effective management. While data on this relatively uncommon surgical procedure are scarce, some referral centers have accumulated extensive experience. This review summarizes relevant surgical aspects and anesthetic insights from the Brigham and Women's Hospital experience. Included are the anesthetic implications of intraoperative intracavitary hyperthermic chemotherapy in combination with extrapleural pneumonectomy - an emerging therapeutic option in the treatment of malignant pleural mesothelioma.
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Recent publications have reported on the neurologic complications in cardiovascular surgery. They are frequent, and have surpassed the mortality rate in cardiac surgery. Brain injury compromises surgical results and the patient's outcome. This review reports on the recent literature on neuromonitoring tools used to prevent and reduce brain injury in cardiovascular surgery. ⋯ Neuromonitoring tools may guide both intervention and treatment, and are aimed at reducing brain damage during cardiovascular surgery, especially when combined in multimodality monitoring. Further prospective, double-blind, randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities) in specific surgical settings.
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While patients with acute heart failure typically receive diuretics and vasodilators, contractile dysfunction and peripheral hypoperfusion also leads to a widespread use of inotropic agents despite the lack of evidence for efficacy or safety. Levosimendan, a calcium sensitizer and vasodilator, has been proposed to be superior to standard inotropes. In addition, further possible indications for levosimendan have been described, such as perioperative use, cardioprotection, cardiogenic shock, sepsis, and right ventricular dysfunction. ⋯ Levosimendan is an established substance in the treatment of acute heart failure in several countries despite disappointing findings concerning a possible survival benefit in two recent clinical trials. Owing to its alternative mechanisms of action as compared with traditional cardiotonic agents, several promising clinical applications have arisen. Available evidence for the use of levosimendan in settings other than decompensated heart failure is currently limited.