Neuromuscular Monitoring in the Perioperative Period.

Neuromuscular monitoring devices were introduced into clinical practice in the 1970s. Qualitative neuromuscular monitors, or peripheral nerve stimulators, provide an electrical stimulus to a motor nerve and the response of corresponding muscle subjectively evaluated. A standard peripheral nerve stimulator provides several patterns of nerve stimulation, including train-of-four (TOF), double-burst, tetanic, and post-tetanic count. Qualitative (and quantitative) monitors are needed to determine onset of neuromuscular blockade, maintain the required depth of muscle relaxation during the surgical procedure, and assess an appropriate dose of reversal agent. However, absence of fade measured with a peripheral nerve stimulator does not exclude residual neuromuscular block; TOF ratios as low as 0.4-0.6 may be present when fade is no longer observed. In addition, the risk of incomplete neuromuscular recovery may be influenced by monitoring site. The adductor pollicis is more sensitive to the effects of neuromuscular blocking agents (compared to the muscles surrounding the eye), and monitoring at this site may more accurately reflect recovery of pharyngeal muscles (the last muscles to recover from the effects of neuromuscular blocking agents, in which dysfunction may persist even at a TOF ratio of 1.0). Quantitative monitors are devices that measure and quantify the degree of muscle weakness and display the results numerically. Several different technologies have been developed, including mechanomyography, electromyography, acceleromyography, kineograph, and phonomyography. Lower doses of anticholinesterases may be used to effectively reverse neuromuscular blockade at TOF ratios of 0.4-0.6; quantitative monitoring is required to determine that this level of neuromuscular recovery has occurred. As clinical tests of muscle strength, peripheral nerve stimulators are unable to determine whether full recovery of neuromuscular function is present at the end of the surgical procedure. The use of quantitative monitors is essential in excluding clinically important muscle weakness (TOF ratios

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Prolongation of Apnea Time in Obese Patients-Concerns With Rate of Rise of CO2.

No abstract available

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The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management.

The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease. (C) 2017 International Anesthesia Research Society

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The Perioperative Surgical Home: A New Role for the Acute Pain Service.

No abstract available

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Differential Roles of the Right and Left Toe Perfusion Index in Predicting the Incidence of Postspinal Hypotension During Cesarean Delivery.

BACKGROUND: Aortocaval compression by the gravid uterus, low baseline vasomotor tone, and spinal anesthesia-related sympathetic blockade contribute to spinal anesthesia-induced hypotension during cesarean delivery. The finger perfusion index (PI) can predict spinal hypotension by reflecting baseline vasomotor tone, but cannot directly reflect aortocaval compression by the gravid uterus. This study aimed to examine whether baseline toe PIs predict the incidence of maternal hypotension and reflect aortocaval compression by the gravid uterus during cesarean delivery under spinal anesthesia. METHODS: One hundred parturients undergoing elective cesarean delivery were enrolled. The relationship between baseline toe PI and the incidence of hypotension following induction of spinal anesthesia was quantified using area under the receiver operator curves, and results compared for the right and left toe PIs. RESULTS: The area under the receiver operator curves for left and right toe baseline PIs were 0.81 (95% confidence interval, 0.71-0.88) and 0.76 (95% confidence interval, 0.66-0.84), respectively. Following induction of spinal anesthesia, the toe PIs did not change in parturients with hypotension, but increased significantly among those who did not develop hypotension. CONCLUSIONS: Our study demonstrated that baseline toe PIs were inversely associated with the incidence of postspinal hypotension during cesarean delivery. Continuous monitoring of toe PIs during induction of spinal anesthesia might help to predict the development of postspinal hypotension and reflect the aortocaval compression by the gravid uterus. (C) 2017 International Anesthesia Research Society

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Reducing Mortality in the Perioperative Period: 2nd ed.

No abstract available

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Future prospect of faecal microbiota transplantation as a potential therapy in asthma

Publication date: Available online 10 August 2017
Source:Allergologia et Immunopathologia
Author(s): Y. Kang, Y. Cai
There is convincing evidence from both human and animal studies suggesting that the gut microbiota plays an important role in regulating immune responses associated with the development of asthma. Certain intestinal microbial strains have been demonstrated to suppress or impair immune responsiveness in asthma experimental models, suggesting that specific species among gut commensal microbiota may play either a morbific or phylactic role in the progression of asthma. Evidence to date suggests that the intestinal microbiota represent fertile targets for prevention or management of asthma. The faecal microbiota transplantation (FMT) is a rather straightforward therapy that manipulates the human gastrointestinal (GI) microbiota, by which a healthy donor microbiota is transferred into an existing but disturbed microbial ecosystem. The FMT may therefore represent a therapeutic approach for asthma treatment in the foreseeable future. At present, FMT therapy for asthma is very limited and should be actively studied. Considerable efforts are needed to increase our knowledge in the field of FMT therapy for asthma. In this review, we aimed to provide several insights into the development of FMT therapy for asthma.



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