Current opinion in critical care
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We presume that biomarkers will improve identification of patients at risk, leading to interventions and treatments that reduce perioperative adverse events. Risk stratification is multifactorial, and a biomarker must add information to this process, thereby redistributing patients to either higher or lower risk categories, to improve the allocation of expensive and risky interventions. This review focuses on the utility of three cardiac biomarkers in perioperative management. ⋯ The findings here suggest an expanded role for postoperative cTn surveillance; however, the precise populations that benefit, or the interventions required, are not yet defined. The encouraging data for the other two biomarkers need more investigations before adopting them into routine clinical use.
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Curr Opin Crit Care · Aug 2013
ReviewReducing perioperative cardiac morbidity and mortality: is this the right goal?
One million people die annually following noncardiac surgery and 4% of patients suffer an adverse cardiac event after surgery. As the number of people having surgery grows, our ability to risk stratify patients becomes more important, particularly in the setting of perioperative myocardial ischemia/necrosis. ⋯ The presence of troponin elevations following noncardiac surgery, particularly in at-risk patients, may enable practitioners to better identify high-risk patients in the postoperative setting. After recognizing those patients at increased risk for poor outcomes, practitioners can then make interventions, which may decrease the patients' in-hospital, 30-day and potentially long-term mortality.
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We discuss the formulation of a prescription for intravenous (i.v.) fluid therapy (a 'volume prescription') for critically ill patients: pros/cons of different fluid types; accurate dosing; and qualitative and quantitative toxicities. Updated physiologic concepts are invoked and results of recent major clinical trials on i.v. fluid therapy in the acutely ill are interpreted. ⋯ Similar to any drug used in acutely ill patients, clinicians ordering a volume prescription must recognize that context is crucial. Physiologically balanced crystalloids may be the 'default' fluid for acutely ill patients, and the role for colloids is unclear. Optimal dosing involves assessment of volume responsiveness.
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This review explores the contemporary definition of the term 'balanced crystalloid' and outlines optimal design features and their underlying rationale. ⋯ The case for balanced crystalloids is growing but unproven. A large randomized controlled trial of balanced crystalloids versus 0.9% sodium chloride is the next step.
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Using perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years. ⋯ GDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.