Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies of neuroprotection for intracranial aneurysms.
Neuroprotection for patients with intracranial aneurysms encompasses the preservation of brain cells endangered by a limited blood and oxygen supply due to aneurysm rupture, clipping or coiling, as well as vasospasm. A large variety of prophylactic and therapeutic neuroprotective strategies have been proposed, but success in human disease is quite limited. ⋯ New concepts are ischaemic preconditioning, growth factors, and gene therapy. Each strategy is rated on underlying evidence, and research agendas are mentioned.
-
Despite advances in our understanding of the neurobiology of nociception, postoperative pain continues to be undertreated. There are many modalities that may provide effective postoperative analgesia, including systemic (e.g. opioids, non-steroidal anti-inflammatory agents) and regional analgesic options. The particular modality or modalities utilized for a particular patient will depend on the risk-benefit profile and patient preferences. Ideally, analgesic options should be incorporated into a multimodal approach to facilitate patient recovery after surgery.
-
With the expansion of ambulatory surgery in the Western world over the last 10 years, it has become increasingly important to identify patients at risk of perioperative complications and to use appropriate methods to decrease these risks. The confidential enquiry into perioperative deaths was one of the first national programmes instituted to identify patients at risk after the operation. Although the focus for this initial enquiry was on perioperative mortality, recent developments have increasingly focused on identification of perioperative morbid events. ⋯ Later, strategies are discussed which could reduce the perioperative general and cardiorespiratory risks in the ambulatory surgical patient. Many of these strategies are derived from the inpatient since appropriate data in outpatients are lacking. Future studies should thus focus on data derived from outpatients and prospective, randomized, double-blind studies in a large population of patients in order to first identify the patient at risk and subsequently to use drugs and techniques that reduce these perioperative risks.
-
The physiological alterations induced by acute inflammation present significant management challenges for anaesthesiologists. Major surgery, trauma, burns and sepsis all have large inflammatory components. Acute inflammation is characterized by vasodilatation, fluid exudation and neutrophil infiltration. ⋯ This syndrome is characterized by hyperinflammation and can cause organ injury, shock and death in its most severe forms. Overall, our understanding of inflammation has increased tremendously during the past 20 years. However, these basic science advances have not yet translated into widespread benefit for patients suffering from trauma, sepsis and systemic inflammation.
-
Surgical manipulation of the gut elicits an inflammatory cascade within the intestinal muscularis that contributes to postoperative bowel dysmotility. A range of cytokines is sequentially released into the peritoneal fluid following abdominal surgery, their concentrations reflecting the magnitude of surgical trauma. ⋯ Laparoscopic surgery decreases the local and systemic production of cytokines and acute-phase reactants, and better preserves peritoneal immunity compared with open surgery. As concluded from animal studies, the gas used for the pneumoperitoneum may possess substantial immunomodulatory activity.