Best practice & research. Clinical anaesthesiology
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Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. ⋯ Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time, allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.
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Best Pract Res Clin Anaesthesiol · Sep 2009
Historical ArticleTraining guidelines for ultrasound: worldwide trends.
Sound travels through objects that block light. Only very recently has technology advanced enough to decipher ultrasound for medical use. Machines have become smaller, cheaper, more versatile and more advanced than ever before. ⋯ There also needs to be an understanding of when broad experience and advanced technical skills are required or when limited skills will do. In addition, some procedures can be performed more safely with ultrasound where the knowledge of ultrasound is not paramount. This article covers current provision of training in echocardiography and ultrasound in areas relevant to anaesthetists who are working in critical care (including accident and emergency) and complex surgery (mainly cardiac).
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The haemodynamic state refers to the integration of myocardial and vascular systems, and involves both left and right hearts, and systolic and diastolic phases. The assessment of the haemodynamic state can be performed with echocardiography, and provides a higher level of diagnosis than conventional pressure- and flow-based monitoring. Whilst hypotension alerts the practitioner about the existence of haemodynamic abnormality, it does not provide sufficient information to identify the cause or the underlying haemodynamic state. ⋯ Patients may have an abnormal haemodynamic state (such a systolic failure), but may not need active treatment if they are haemodynamically stable. However, if treatment is required, it can be directed according to the underlying haemodynamic state. For example, a patient with systolic failure may benefit from inotrope support, whereas an empty state acquires volume infusion and vasodilation requires vasopressor support.
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewRelevance of non-albumin colloids in intensive care medicine.
Current guidelines on initial haemodynamic stabilization in shock states suggest infusion of either natural or artificial colloids or crystalloids. However, as the volume of distribution is much larger for crystalloids than for colloids, resuscitation with crystalloids alone requires more fluid and results in more oedema, and may thus be inferior to combination therapy with colloids. This chapter describes the currently available synthetic colloid solutions [i.e., dextran, gelatin and hydroxyethyl starch (HES)] in detail, and critically discusses their specific effects including potential adverse effects. ⋯ When considering the efficacy and risk/benefit profile of synthetic colloids, modern tetrastarches appear to be most suitable for intensive care medicine, given their high volume effect, low anaphylactic potential and predictable pharmacokinetics. However, the impact of tetrastarch solutions on mortality and renal function in septic patients has not been fully determined, and further comparison with crystalloids in prospective, randomized studies is required. Such studies are currently ongoing and their results should be awaited before drawing final conclusions on the HES preparations.
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For decades, the 'third space' was looked upon as an actively consuming compartment. Therefore, perioperative fluid regimens were traditionally based on a generous replacement of this assumed primary loss, in addition to deficits due to insensible perspiration and fasting. The practical consequence was an extremely positive fluid balance in order to maintain blood volume during major surgery. ⋯ Such shifting is related to a destruction of the endothelial glycocalyx, a key structure of the vascular barrier, by traumatic inflammation and iatrogenic hypervolaemia. This explains why patients undergoing major surgical interventions benefit significantly from an infusion regimen which does not substitute but avoids 'third-space shifting'. In summary, eradicating this notion from our minds could be a further key to achieving perioperative fluid optimisation.