Anesthesiology clinics
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As outlined in Table 1, the nonthermodilution techniques available to measure cardiac output are noninvasive and clinically applicable to a variable degree. The truly noninvasive monitors are bioimpedance and CO2 re-breathing. The latter, however, requires the patient to be intubated, and the former continues to be evaluated with regard to correlation with the thermodilution standard. ⋯ Pulse contour analysis requires an arterial catheter, and two of the three available monitors require external calibration, while the third has not been validated adequately. The reader can see that all four approaches continue to be refined, with new analysis algorithms and monitors continuing to appear on the market. In the absence of true tissue oxygenation monitors, it seems likely that some or all of these alternatives to thermodilution will play a greater role in the care of patients where measurement of cardiac output is desired.
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Anesthesiology clinics · Dec 2006
Intraoperative monitoring with transesophageal echocardiography: indications, risks, and training.
There are benefits and risks to the use of TEE. The benefits are derived from the physiologic information that TEE provides, which may not be as readily obtained by any other technique. The risks of TEE are those related to mechanical trauma from the probe, as well as those of an incorrect TEE interpretation by the echocardiographer. ⋯ The authors have discussed some of the issues involved with each class-I indication. Performance of the TEE is not an end in itself and should not distract the anesthesiologist from the primary goal of patient care. With proper training and experience, the anesthesiologist may learn how to use TEE to improve patient care.
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Pressure monitoring systems influence the contour of the displayed wave-forms and, on occasion, can introduce significant artifact in the pressure traces. It is important to understand the technical details of invasive pressure monitoring to interpret better the information presented. Careful observation of the arterial pressure waveform can provide information about ventricular function, the arterial system, and ventricular preload. ⋯ CVP monitoring is also used to assess intravascular volume, but this measurement is significantly influenced by ventricular compliance and intrathoracic pressure. Under most clinical circumstances, a trend in CVP values or its change with therapeutic maneuvers is more reliable than a single measurement. Like arterial pressure waveforms, CVP waveform morphology can provide important information about clinical pathophysiology.
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Exposures to toxins are prevalent, frequently complicate surgical emergencies, and impact critical care. A fundamental understanding of pathophysiologic principles and management strategies is essential for the anesthesiologist frequently responsible for the acute care of patients who have toxicologic exposures. Given their pervasiveness and ability to confound the clinical presentations in the perioperative or intensive care setting, substances of abuse and asphyxiants warrant particular attention and a high degree of vigilance.
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Anesthesiology clinics · Jun 2006
ReviewPast accomplishments and future directions: risk prevention in anesthesia and surgery.
Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. ⋯ The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.