Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: focus on the perioperative setting.
The benefits of tight glycaemic control (TGC) were first shown in cardiac surgical patients with diabetes. These concepts migrated to other surgical and medical specialties through intensive care units caring for a variety of patients with a variety of disease states Although some disagreement and controversy surrounds the use of TGC in the medical population, the benefits of this therapy ir the diabetes cardiac surgery population is unblemished. Perioperative hyperglycaemia has been shown to be associated with adverse surgical outcomes in several different patient populations TGC for 3 full postoperative days or more mitigates these risks Although this has been definitively proven in the diabetes coronary artery bypass graft (CABG) population, evidence for beneficia effects of TGC in other surgical populations remains elusive at this point in time. In this article, we explore the risks of hyper- and hypoglycaemia in the surgical patient; safety and efficacy of insulin protocols in the surgical population, target range goals and dura tion of therapy; the beneficial effects of TGC on decreasing mortality, reducing infectious complications, length of stay and other complications; define target surgical populations tha benefit from TGC; analyse current controversies as they relate to surgical populations; and describe questions that remain for the future of TGC.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewThe impact of routine trans-oesophageal echocardiography (TOE) in cardiac surgery.
Trans-oesophageal echocardiography (TOE) has profoundly changed cardiac surgery and the role of the cardiac anaesthesiologist. It has been the driving force for a real-time diagnostic and decision-making partnership between cardiac anaesthesiologists and cardiac surgeons that has significantly advanced the safety and effectiveness of modern cardiac surgery. With the information provided by TOE, anaesthesiologists and surgeons may redirect the care of cardiac surgical patients to decrease morbidity and mortality. ⋯ While some colleagues continue to question whether TOE should be used routinely in all cardiac surgical patients, we believe that it is impossible to predict in which cardiac patients TOE will discover vitally important new information. Therefore, we recommend that in the absence of contraindication to oesophageal instrumentation with the probe, TOE should be performed in all cardiac surgical patients. With routine TOE use, TOE will have its greatest benefit.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewUltrasound guided vascular access: efficacy and safety.
Central venous catheterisation and arterial catheterisation are common procedures performed by anaesthetists. Traditionally, the technique of locating surface landmarks and palpation was used to assist in vascular access. ⋯ In the United States and United Kingdom, guidelines have recommended the use of ultrasound guidance to reduce complications and improve success in central venous catheterisation. This article summarises the literature on complication rates, efficacy and safety of ultrasound-guided vascular access procedures and describes a practical method of ultrasound-guided central venous access and arterial catheterisation.
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Ultrasound is used in anaesthesia for diagnostic and interventional reasons. This article gives the anaesthesiolgoist an overview about the relevant indications for ultrasound in non-cardiac surgical patients. Other chapters will focus in more detail on different aspects of ultrasound use in non-cardiac anaesthesia. ⋯ The use of transcutaneous ultrasound in anaesthesia is mainly interventional: The puncture rate for vascular access e.g. central venous catheterization is higher and the procedure can be performed safer under continuous sonographic guidance. Nerve blockade under direct visualisation of target and accompanying structures has amplified the regional anaesthetic methods. The major nerve blocks are described and discussed.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewGoal-directed fluid management with trans-oesophageal Doppler.
Major surgery is associated with significant trauma and is a potential cause of multiple system organ failure and death. Measurement of cardiac output using a variety of techniques during the perioperative period has enabled practitioners to proactively optimise stroke volume and cardiac output in an attempt to reduce postoperative complications. ⋯ Oesophageal Doppler ultrasonography is a minimally invasive method for measuring stroke volume and cardiac output. It is user-friendly and is one of the few low-invasive technologies to date, which has been used successfully to guide intra-operative fluid administration, resulting in improvement in outcome and significant reduction in duration of hospital stay.