Minerva anestesiologica
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Minerva anestesiologica · Nov 2013
ReviewNoninvasive ventilation in acute respiratory failure with altered consciousness syndrome: a bargain or an hazard?
Non-invasive ventilation (NIV) is contraindicated or at least not recommended in patients with altered consciousness syndrome (ACS) given to the poor compliance of confused/agitated patients, difficult management of accumulated secretion in depressed cough reflex, and risk of aspirative pneumonia in absence of airways protection. Conventional mechanical ventilation (CMV) via endotracheal intubation (ETI) has been usually considered as the "golden standard" ventilator treatment in ACS. However, the possibility of avoiding ETI-related life-threatening complications by means of NIV, especially in fragile, older patients with multiple comorbidities, is an appealing option. ⋯ In this clinical scenario, an initial cautious NIV trial may be attempted as long as there are no other contraindications and the technique is provided by experienced caregivers in a closely monitored setting where ETI is always readily available. The concomitant use of techniques for removing secretion and/or controlled analgo-sedation performed by expert teams may be considered in highly selected cases. The purpose of this paper was to review rationale, clinical feasibility, advantages and risks correlated with the use of NIV in ACS.
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Sepsis remains a major cause of admissions to Intensive Care Units (ICU) and has a high mortality rates and significant morbidity in survivors. There are physical, cognitive and psychological sequelae from severe sepsis that have a negative effect on the patients' health related quality of life in the longer term and a social care and humanitarian impact. Although muscle mass loss during the septic period happens very quickly, recovery takes a considerable time and requires the patient to commit to exercising and eating well to rebuild. ⋯ The use of techniques such as ICU diaries to help patients to understand their illness and deal with delusional memories they may have from their ICU stay has been shown to aid psychological recovery in general ICU patients, a percentage of whom will have suffered from sepsis. The use of a self-guided manualised 6 week rehabilitation program, the ICU Recovery Manual, has been shown to accelerate physical recovery in general ICU patients. Considerable amounts of money are spent treating patients with severe sepsis in ICU and not completing the job of returning them to as close as possible to their normal functioning does not make financial sense.
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Minerva anestesiologica · Nov 2013
ReviewRegional anesthesia in patients with significant comorbid disease.
An increasing body of evidence suggests that regional anesthesia does not only provide better pain control compared to systemic analgesic and anesthetic techniques but that it is associated with improved perioperative outcomes. As these benefits may be especially prominent in the patient population suffering from high comorbidity burden, anesthesiologists have to be familiar with associated factors that may complicate the decision to use regional anesthetics. This manuscript is intended to provide a brief overview of the recent literature regarding beneficial outcomes associated with the use of regional versus general anesthesia, before focusing on the discussion of the implications of specific comorbid states on the performance of regional anesthetic techniques.