Minerva anestesiologica
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Minerva anestesiologica · Oct 2017
ReviewBrain monitoring in adult and pediatric ECMO patients: the importance of early and late assessments.
Monitoring brain integrity and neurocognitive function is a new and important target for the management of a patient treated with extracorporeal membrane oxygenation (ECMO), in particular because of the increasing awareness of cerebral abnormalities that may potentially occur in this setting. Continuous regular monitoring, as well as repeated assessment for cerebral complications has become an essential element of the ECMO patient management. Besides well-known complications, like bleeding, ischemic stroke, seizures, and brain hypoperfusion, other less defined yet relevant injury and clinical manifestations are increasingly reported and impacting on ECMO patient prognosis at short term. ⋯ Despite increasing awareness of these aspects, generally accepted protocols and clinical management strategies in this respect are still lacking. Current means to monitor brain perfusion or detecting ongoing cerebral tissue injury are rather limited, and most techniques provide indirect or post-insult recognition of irreversible tissue injury. Continuous monitoring of brain perfusion, serial assessment of brain-derived serum biomarkers, timely neuro-imaging, and post-discharge counselling for neurocognitive dysfunction, particularly in pediatric patients, are novel pathways focusing on neurologic assessment with important implications in daily practice to assess brain function and integrity not only during the ECMO-related hospitalization, but also at long-term to re-evaluate the neuropsychological integrity, although well designed studies will be necessary to elucidate the cost-effectiveness of these management strategies.
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Mechanical ventilation is a cornerstone of the intraoperative management of the surgical patient and is still mandatory in several surgical procedures. In the last decades, research focused on preventing postoperative pulmonary complications (PPCs), both improving risk stratification through the use of predictive scores and protecting the lung adopting so-called protective ventilation strategies. The aim of this review was to give an up-to-date overview of the currently suggested intraoperative ventilation strategies, along with their pathophysiologic rationale, with a focus on challenging conditions, such as obesity, one-lung ventilation and cardiopulmonary bypass. ⋯ Due to the high number of surgical procedures performed daily, the impact on patients' health and healthcare costs can be relevant, even when new strategies result in an apparently small improvement of outcome. A protective intraoperative ventilation should include a low tidal volume of 6-8 mL/kg of predicted body weight, plateau pressures ideally below 16 cmH2O, the lowest possible driving pressure, moderate-low PEEP levels except in obese patients, laparoscopy and long surgical procedures that might benefit of a slightly higher PEEP. The work of the anesthesiologist should start with a careful preoperative visit to assess the risk, and a close postoperative monitoring.
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Minerva anestesiologica · Oct 2017
Observational StudyThoracic trauma and acute respiratory distress syndrome in polytraumatized patients admitted to a level I trauma center: a retrospective analysis.
Although thoracic trauma has often been associated with the development of acute respiratory distress syndrome (ARDS) in general, its impact on ARDS in combination with severe concomitant injuries has still to be elucidated. Therefore, the objective of this study was to determine the frequency of thoracic trauma and ARDS in polytraumatized patients, and to evaluate the impact of thoracic trauma on the occurrence and the onset of ARDS. ⋯ Thoracic trauma was identified as major risk factor for ARDS occurrence and earlier onset in polytrauma victims.
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Minerva anestesiologica · Oct 2017
ReviewContinuous regional anesthesia: a review of perioperative outcome benefits.
Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. ⋯ To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.
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Minerva anestesiologica · Oct 2017
Randomized Controlled Trial Comparative StudyComparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial.
BACKGROUNDː Lowering central venous pressure (CVP) can decrease blood loss during liver resection and it is associated with improved outcomes. Multiple CVP reducing maneuvers have been described, but direct comparison of their effectiveness and safety has never been performed. METHODSː Patients undergoing resections of two or more liver segments were equally randomized to absolute fluid restriction (AR, N.=17) or relative volume redistribution group (RR, N.=17). ⋯ CONCLUSIONSː In our study, absolute fluid restriction and relative volume redistribution seemed to be equally effective and safe methods of lowering CVP in patients undergoing liver resection. According to our data high SVV might be considered as a low CVP replacement. Pringle maneuver reduced blood loss and transfusion requirement.