Minerva anestesiologica
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Minerva anestesiologica · Jun 2008
ReviewQuality and quantity of volume replacement in trauma patients.
An epidemiologic evaluation of trauma-related deaths in trauma centers reveals that the majority of patients die within 6 hours from exsanguination, whereas secondary brain injuries predominate between 6 and 24 hours. Late deaths remain attributable to sepsis and pulmonary embolism,1-3 while early deaths are due in part to multiple bleeding injuries or to a set of complex and untreatable injuries, mainly of the liver and pelvis. Before trauma systems existed, these patients died at the scene of the trauma, whereas since the establishment of the trauma system, they die in emergency or operating rooms. ⋯ Moreover, increases in blood pressure before surgical hemostasis have been shown to disrupt clotting and increase bleeding, a fact that has been confirmed by a number of animal and human studies on uncontrolled hemorrhage. Furthermore, oxygen must be delivered to vital organs (brain, heart) to prevent death during hemorrhage. In summary, several constraints account for the differences in fluid use, timing of infusions, and determinations of whether to administer fluids at all.
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Ischemic heart disease is the major cause of morbidity and mortality in the Western world. With the advancing age of the surgical population, anesthesiologists increasingly have to treat patients with known or suspected ischemic heart disease in the perioperative period. Over the years various strategies have been developed to prevent myocardial ischemia in the perioperative period and/or to minimize the extent of myocardial damage after perioperative ischemia. This review summarizes the current knowledge on the subject and focuses on the more recent data concerning perioperative cardioprotection by anesthetic agents.
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Minerva anestesiologica · Jun 2008
An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock.
Septic shock is highly lethal. We recently implemented an algorithm (advanced resuscitation algorithm for septic shock, ARAS 1) with a global survival of 67%, but with a very high mortality (72%) in severe cases [norepinephrine (NE) requirements >0.3 microg/kg/min for mean arterial pressure > or =70 mmHg]. As new therapies with different levels of evidence were proposed [steroids, drotrecogin alpha, high-volume hemofiltration (HVHF)], we incorporated them according to severity (NE requirements; algorithm ARAS-2), and constructed a multidisciplinary team to manage these patients from the emergency room (ER) to the ICU. The aim of this study was to compare the outcome of severe septic shock patients under both protocols. ⋯ Management of severe septic shock with these kinds of algorithms is feasible and should be encouraged.
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Minerva anestesiologica · Jun 2008
Randomized Controlled Trial Multicenter Study Comparative StudySufentanil-propofol vs remifentanil-propofol during total intravenous anesthesia for neurosurgery. A multicentre study.
In a randomised, prospective multi-centre study, we compared the intraoperative and postoperative effects of two opioids: sufentanil and remifentanil, in combination with propofol in two groups of patients undergoing neurosurgery. ⋯ There were no significant differences between the groups in the duration of surgery and anesthesia, mean arterial pressure, heart rate, time to eye opening or extubation. The incidence of vomiting, respiratory depression and shivering was similar in both groups. Postoperative pain requiring supplemental analgesics was significantly lower in the sufentanil group (P<0.05). Although there were no significant differences between the groups in postoperative behavioural examinations by Rancho Los Amigos Test, patients anesthetised with sufentanil had significantly better Short Orientation-Memory-Concentration Test values at 15 and 180 min postoperatively (P<0.05). CONCLUSION. We conclude that remifentanil and sufentanil are suitable adjunct to propofol for total intravenous anesthesia (TIVA). Patients receiving sufentanil have reduced analgesic requirements and better cognitive function postoperatively than those who received remifentanil.
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Minerva anestesiologica · Jun 2008
ReviewHypothermia for brain protection in the non-cardiac arrest patient.
This review focuses on the potential application of hypothermia in adults suffering traumatic brain injury (TBI). Hypothermia is neuroprotective, reducing the damaging effects of trauma to the brain in a variety of experimental situations, such as brain ischemia and brain injury, but it has failed to demonstrate outcome improvement in a major controlled, randomized trial. ⋯ However, evidence does suggest that hypothermia is effective in reducing intracranial hypertension after head injury. Since hypothermia has important side effects, further work is necessary before introducing this procedure into clinical practice for TBI.