Minerva anestesiologica
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Minerva anestesiologica · May 2011
ReviewGoal-directed therapy in anesthesia: any clinical impact or just a fashion?
Goal-directed therapy (GDT) describes the protocolized use of cardiac output and related parameters as end-points for fluid and/or inotropic therapy administration. Identifying the patient who will benefit from it has implications throughout perioperative management. The fundamental principle behind GDT is optimizing tissue perfusion by manipulating heart rate, stroke volume, hemoglobin and arterial oxygen saturation to improve oxygen delivery by using fluids, inotropes, red blood cells and supplementary oxygen. ⋯ To date, the quantity and the type of fluids to administer during major elective surgery remain an object of continuing debate. In conclusion, in terms of evidence-based medicine, GDT during anesthesia has a clinical impact when performed using an FTc-based fluids algorithm protocol. In contrast, GDT can be considered unreliable if confusing targets such as SvO2 or ScvO2 higher than 70% during anesthesia are followed.
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Minerva anestesiologica · May 2011
ReviewCurrent trends in simulation training in anesthesia: a review.
Anesthesiology as a specialty has made numerous prescient commitments to better patient care. Physicians entering residency are reaching the zenith of their educational odyssey and primarily acquire knowledge and skill through active involvement. Simulation training and associated assessment offers a chance for active involvement to the learner. ⋯ This increase in skill is expected to translate to evidence of improved patient care. Direct evidence that simulation directly improves patient care continues to be difficult to establish. In the future, the intuitive benefit of simulation as a means to improve the safety and quality of patient care is likely to become established by clinical research.
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Hypoxemia is considered to be the most important challenge during one-lung ventilation (OLV). Recent studies, however, have shown that one-lung ventilation can involve some lung damage and can therefore be per se a cause of hypoxemia. OLV can be associated to an injury: but the techniques used to improve oxygenation may also damage the lung. A new ventilator approach should be used and applied with regards to what is so far known in terms of "lung protection" also during OLV.
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Minerva anestesiologica · May 2011
ReviewProtective and ultra-protective ventilation: using pumpless interventional lung assist (iLA).
Acute lung failure is associated with high mortality and usually requires mechanical ventilation to ensure adequate gas exchange. However, mechanical ventilation itself can be associated with major complications and can aggravate pre-existing lung disease, thus contributing to morbidity and mortality. ⋯ In contrast to veno-venous extracorporeal membrane oxygenation (ECMO), pumpless extracorporeal interventional lung assist (iLA) is applied via an arterio-venous bypass into which a gas exchange membrane is integrated. iLA allows for efficient carbon dioxide removal, which allows for a significant reduction in ventilator settings. iLA may be a useful tool in protective or even 'ultraprotective' ventilation, enabling the application of very low tidal volumes in patients with acute respiratory failure of different etiologies. This article reviews the current status and the potential role of interventional (pumpless) lung-assist iLA within the context of lung-protective ventilation strategies.