Current opinion in anaesthesiology
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Hemorrhage after traumatic injury results in coagulopathy which only worsens the situation. This coagulopathy is caused by depletion and dilution of clotting factors and platelets, increased fibrinolytic activity, hypothermia, metabolic changes and anemia. ⋯ Bedside coagulation monitoring permits relevant impairment of the coagulation system to be detected very early and the efficacy of the hemostatic therapy to be controlled directly. Administration of fresh frozen plasma, platelet concentrations, clotting factors and probably antifibrinolytic agents is essential in restoring the impaired coagulation system in trauma patients.
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Primary emergency medicine systems in developed countries are well organized. Besides this primary system a secondary interhospital transport system has been developed in the past decade. ⋯ This article outlines the current status of these secondary interhospital transfer systems, their components, possibilities, advantages or disadvantages, and the actual literature. Surprisingly, the available scientific data on these cost-intensive and highly developed systems are quite insufficient.
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In the last few years, video assisted thoracoscopy, which allows a wide variety of diagnostic and therapeutic procedures, has been introduced into clinical practice. A growing enthusiasm for minimally invasive surgical approaches and improvements in video endoscopic surgical equipment has resulted in the widespread use of this technique. Most video assisted thoracoscopy procedures require a well-collapsed lung and should only be included in the absolute indication for one-lung ventilation. ⋯ Finally, there are alternatives to the use of the double-lumen tube to achieve lung separation, such as the Univent tube or an independent bronchial blocker. In many situations the double-lumen tube cannot be inserted, due to a difficult airway or at the conclusion of the procedure changing the double lumen tube to a single lumen tube may result in loss of control over the airway. In such situations, it is essential for the anesthesiologists to be familiar with the existing alternatives to the double-lumen tube.
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Mechanical ventilation is a life-supporting process employed in the management of respiratory failure. Over the years, our understanding of the pathophysiology of lung injury has greatly improved, and has aided the technological development of ventilatory modes that are more patient 'sensitive' and less traumatizing to the lungs. This review will discuss the fundamental modes of mechanical ventilation, and present current concepts regarding patient-ventilator interaction that either promote lung healing and weaning from positive pressure ventilation or delay recovery because of the injudicious use of ventilatory modalities that are incapable of meeting the ventilatory demands of the patient on a breath-by-breath basis. In addition, the current strategy for mechanical ventilation in acute lung injury and acute respiratory distress syndrome will be summarized.
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Recently, there has been considerable interest in regional anaesthetic techniques, particularly in peripheral nerve blockade, for orthopaedic limb surgery. Many traditional nerve-block techniques have been significantly modified to improve their role in both in-patient and out-patient surgery. The introduction of long-acting local anaesthetic with a better safety profile as well as better equipment for continuous nerve blockade has further increased the use of such techniques in the provision of postoperative analgesia. The recent developments described in this review are likely to result in wider use of these techniques in years to come.