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Balancing volume resuscitation and ascites management in cirrhosis.

Curr Opin Anaesthesiol. 2010 Apr;23(2):151-8

Authors: Polli F, Gattinoni L

PURPOSE OF REVIEW: Patients with cirrhosis have total extracellular fluid overload but central effective circulating hypovolaemia. The resulting neurohumoral compensatory response favours the accumulation of fluids into the peritoneal cavity (ascites) and may hinder renal perfusion (hepatorenal syndrome). Their deranged systemic haemodynamics (hyperdynamic circulatory syndrome) is characterized by elevated cardiac output with decreased systemic vascular resistance and low blood pressure. RECENT FINDINGS: Molecular and biological mechanisms determining cirrhosis-induced haemodynamic alterations are progressively being elucidated. The need for a goal-directed assessment of volume resuscitation (especially with volumetric techniques) in patients with cirrhosis is becoming more and more evident. The role of fluid expansion with albumin and the use of splanchnic vasopressors in a variety of cirrhosis-related conditions has recently been investigated. SUMMARY: The response to fluid loading in patients with advanced cirrhosis is abnormal, primarily resulting in expansion of their noncentral blood volume compartment. Colloid solutions, in particular albumin, are best used in these patients. Albumin may be effective in preventing the haemodynamic derangements associated with large-volume paracentesis (paracentesis-induced circulatory dysfunction), in preventing renal failure during spontaneous bacterial peritonitis and, in association with splanchnic vasopressors, in caring for patients with the hepatorenal syndrome.

PMID: 20124894 [PubMed - indexed for MEDLINE]

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Anesthesia for patients with severe chronic obstructive pulmonary disease.

Curr Opin Anaesthesiol. 2010 Feb;23(1):18-24

Authors: Edrich T, Sadovnikoff N

PURPOSE OF REVIEW: Patients with chronic obstructive lung disease experience an increased risk of perioperative pulmonary complications. This review presents an evidence-based approach to perioperative care designed to optimize management. RECENT FINDINGS: Recent research has provided guidance regarding intraoperative and postoperative administration of oxygen and the selective use of volatile agents. The significance of preoperative malnutrition and postoperative epidural analgesia on outcomes has also been explored further. The opportunity for anesthesiologists to engage in tobacco interventions and the benefits of addressing smoking cessation have been studied. SUMMARY: Optimization for surgery includes preoperative treatment of reversible airway obstruction and respiratory infections, smoking cessation, and possibly nutritional interventions. Meticulous intraoperative monitoring combined with a sound understanding of pathophysiological mechanisms underlying air trapping will help clinicians strike a balance between permissive hypercapnia and adequate ventilation.

PMID: 19770646 [PubMed - indexed for MEDLINE]

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Progress in pain assessment: the cognitively compromised patient.

Curr Opin Anaesthesiol. 2008 Oct;21(5):610-5

Authors: Chapman CR

PURPOSE OF REVIEW: Pain assessment is essential for patient care in many settings, but it proves difficult when the patient is cognitively compromised or otherwise unable to produce a conventional pain report. The present review describes the progress in pain assessment technology that involves the coding of human facial expression. RECENT FINDINGS: It is possible to quantify facial expression by coding patterns of facial muscle contraction and relaxation. These patterns are action units, and they can gauge the intensity of pain as well as signal its occurrence. The experience of pain seems to generate a unique facial expression comprising several action units. Concerns have existed about whether demented patients produce diagnostically meaningful facial expressions of pain because they tend to generate more nonspecific facial expressions and perhaps code pain intensity less well than normals. Recent work shows that facial expression reflects pain as well or better in demented patients compared with normals. SUMMARY: Although still nascent, coded facial expression appears to work reliably as a pain assessment tool with cognitively compromised patients. Clinical application awaits the development of technology that can automate facial coding and scoring.

PMID: 18784487 [PubMed - indexed for MEDLINE]

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Acute neuropathic pain: diagnosis and treatment.

Curr Opin Anaesthesiol. 2008 Oct;21(5):590-5

Authors: Gray P

PURPOSE OF REVIEW: Acute neuropathic pain (ANP) is a condition that is under-recognized, often difficult to treat and one that may progress to persistent pain and disability. This review examines the diagnosis and treatment in order to assist clinicians in providing better care to patients with this debilitating pain. RECENT FINDINGS: The recent development of psychometric scales for the detection of neuropathic pain may assist in diagnosing ANP, though this is yet to be tested. Specific research into the treatment of ANP is sparse. However, several recent trials have shown that both tramadol and gabapentin are useful in mitigating neuropathic cancer pain. In addition, a recent trial suggests a combination of neural blockade with memantine may be useful in reducing ANP. SUMMARY: The diagnosis of ANP is assisted by knowledge of the medical circumstances that have a higher risk of the condition developing, a detailed pain history with a directed examination and use of neuropathic pain scales. Although the data are lacking, agents that have demonstrated efficacy in persistent neuropathic pain states should be used in ANP. Refractory ANP could be treated with either intravenous lidocaine or calcitonin. Future research should be directed at validating a scale of neuropathic pain in ANP and conducting more therapeutic trials.

PMID: 18784484 [PubMed - indexed for MEDLINE]

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Vasopressor use in septic shock: an update.

Curr Opin Anaesthesiol. 2008 Apr;21(2):141-7

Authors: Leone M, Martin C

PURPOSE OF REVIEW: This article reviews new findings on the use of vasopressor agents in septic shock. RECENT FINDINGS: Several recent large randomized clinical trials have compared vasopressor agents in patients with septic shock. Briefly, the survival of patients treated with norepinephrine alone or a combination of norepinephrine and dobutamine did not significantly differ from that of patients treated with epinephrine. In observational studies, dopamine use was associated with poor outcome. The results of a clinical trial comparing dopamine and norepinephrine as a first-line agent in septic shock are pending. The addition of low-dose vasopressin to norepinephrine did not significantly improve the survival of patients with septic shock. A positive effect on survival was observed in a predetermined (norepinephrine dose <15 microg/kg/min) subgroup of patients with moderate shock. There is no large randomized clinical trial on the use of terlipressin. In contrast, nitric oxide inhibitors were associated with increased mortality in patients with septic shock. SUMMARY: The use of norepinephrine or epinephrine can be left to the discretion of the treating physician. Low-dose vasopressin administration remains an option for catecholamine-refractory septic shock. The potential benefit of early use in combination with a moderate dose of norepinephrine remains to be determined.

PMID: 18443479 [PubMed - indexed for MEDLINE]

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