Best Practice & Research Clinical Anaesthesiology RSS feed: Current Issue. In practical paperback format, each 200 page topic-based issue of Best Practice & Research Clinical Anaesthesiology will provide a comprehensive review of current clinical practice and thinking within the specialty anaesthesiology. All chapters are commissioned and written by an international team of practicing clinicians with the Guest Editors for each issue drawn from a pool of renowned experts and opinion leaders. Reference is made to: • the latest original research • Cochrane Reviews • audits and confidential enquiries • national and international conferences • national and international guidelines • personal communications All chapters take the form of practical, evidence-based reviews that seek to address key clinical issues of diagnosis, treatment and patient management. Each issue follows a problem-orientated approach that focuses on the key questions to be addressed, clearly defining what is known and not known. Management will be described in practical terms so that it can be applied to the individual patient. Boxed and bulleted Learning Objectives and Practice Points are features within each chapter and will highlight the core and essential knowledge that will help the physician to provide the best care to their patients. The series' objective is to provide a continuous update for the busy clinician and researcher. 2010 topics, Volume 24, Issues 1-4 Vol. 24:1 March - Perioperative coagulation management D. Spahn & M.T. Ganter Vol. 24:2 June - Perioperative respiratory managment P. Pelosi & C. Gregoretti Vol. 24:3 September -Neonatal anaesthesia A.J. Davidson Vol. 24:4 December - The state of neuroprotection C. Werner 2009 topics, Volume 23, Issues 1-4 Vol. 23:1 March - Information technology in anaesthesia & critical care G Meyfroidt & G Van Den Berghe (Germany) Vol. 23:2 June - Volume replacement in anaesthesia and intensive care H Van Aken & J Scholz (Germany) Vol. 23:3 September - Ultrasoundin anaesthesia and intensive care C Royce (Australia) Vol. 23:4 December - Diabetes of injury: implications for anaesthesia & intensive care G Van Den Berghe & B Ellger (Netherlands)http://www.clinicalanaesthesiology.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Best Practice & Research Clinical Anaesthesiology1521-6896241March 2010 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.clinicalanaesthesiology.com/article/PIIS1521689610000078/abstract?rss=yesEditorial Board10.1016/S1521-6896(10)00007-8Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7iiiiiihttp://www.clinicalanaesthesiology.com/article/PIIS1521689609000925/abstract?rss=yesIn the past years, there has been a renewed interest in haemostasis and its management in the perioperative period. The clotting cascade has been replaced by a cell-based representation of coagulation and there has been a thorough interest to understand not only a single part but the overall picture of the coagulation system in the perioperative period with its pro-coagulant as well as anti-coagulant and fibrinolytic control mechanisms. Furthermore, a new respect for the endothelium as an active driver of these processes has been established recently.Perioperative coagulation managementMichael T. Ganter, Donat R. Spahn10.1016/j.bpa.2009.10.002Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7viiviiihttp://www.clinicalanaesthesiology.com/article/PIIS1521689609000706/abstract?rss=yesPerioperative coagulopathy impacts on patient outcome by influencing final blood loss and transfusion requirements. The recognition of pre-existing disturbances and the basic understanding of the principles of and dynamic changes of haemostasis during surgery are pre-conditions for safe patient management. The newly developed cellular model of coagulation facilitates the understanding of coagulation, thereby underscoring the importance of the tissue factor-bearing cell and the activated platelet. Amount of blood loss as well as amount and type of fluids used are the main factors involved in the development of dilutional coagulopathy, which is the most frequently observed cause of coagulopathy in the otherwise healthy surgical patient. Recent data from studies using viscoelastic coagulation studies confirm the central role of fibrinogen in stable clot formation and provide essential knowledge about its changes during blood loss and fluid administration. Besides early decrease in clot firmness during mild-to-moderate dilution, profound dilution results in a critical decrease in thrombin generation as well as a reduction in numbers and function of platelets. Although our knowledge of perioperative coagulopathy has dramatically increased over the past few years, several questions such as critical thresholds for fibrinogen, platelets, impact of FXIII and TAFI remain unanswered and need to be investigated further.Principles of perioperative coagulopathyPetra Innerhofer, Joachim Kienast10.1016/j.bpa.2009.09.006Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7114http://www.clinicalanaesthesiology.com/article/PIIS1521689609000743/abstract?rss=yesAbnormal coagulation parameters can be found in 25% of trauma patients with major injuries. Furthermore, trauma patients presenting with coagulopathy on admission have worse clinical outcome. Tissue trauma and systemic hypoperfusion appear to be the primary factors responsible for the development of acute traumatic coagulopathy immediately after injury. As a result of overt activation of the protein C pathway, the acute traumatic coagulopathy is characterised by coagulopathy in conjunction with hyperfibrinolysis. This coagulopathy can then be exacerbated by subsequent physiologic and physical derangements such as consumption of coagulation factors, haemodilution, hypothermia, acidemia and inflammation, all factors being associated with ongoing haemorrhage and inadequate resuscitation or transfusion therapies. Knowledge of the different mechanisms involved in the pathogenesis of acute traumatic coagulopathy is essential for successful management of bleeding trauma patients. Therefore, early evidence suggests that treatment directed at aggressive and targeted haemostatic resuscitation can lead to reductions in mortality of severely injured patients.New insights into acute coagulopathy in trauma patientsMichael T. Ganter, Jean–François Pittet10.1016/j.bpa.2009.09.010Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-71525http://www.clinicalanaesthesiology.com/article/PIIS1521689609000731/abstract?rss=yesPerioperative coagulation monitoring is the rational diagnostic basis for pro- and anti-thrombotic interventions in patients undergoing emergency and elective surgery. The main goal of perioperative monitoring of haemostasis is to increase safety of patients undergoing surgical procedures.Currently, there is a change in paradigm with (1) increasing implementation of evidence-based approach to preoperative patient evaluation with laboratory coagulation testing secondary to the results of the standardised bleeding history and (2) awareness of the limitations of routine coagulation tests to guide coagulation management in massive bleeding. Alternatively, visco-elastic point-of-care monitoring is increasingly used worldwide. This innovative methodology triggers a trend towards an ‘early goal-directed coagulation management’ focussing on potent coagulation factor concentrates. Practicability, cost-effectiveness, safety and – above all – growing scientific evidence support this concept, and lively discussions among anaesthesiologists and various medical disciplines may help to refine it. The present review focusses on the following key issues of perioperative coagulation monitoring:Perioperative coagulation monitoringSibylle A. Kozek-Langenecker10.1016/j.bpa.2009.09.009Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-72740http://www.clinicalanaesthesiology.com/article/PIIS152168960900072X/abstract?rss=yesInterruption or maintenance of anti-platelet agents (APAs) during surgical or invasive procedures is associated with an increase in cardiovascular or haemorrhagic complications, respectively. The pharmacology and indications of aspirin, clopidogrel and prasugrel are summarised. The utility and risks of interruption, the optimal delay between stent implantation and surgery, the appropriate window of preoperative interruption, the potential usefulness of bridging, the safest delay between the end of surgery and resumption of APA are detailed in this review. Some non- evidence-based suggestions are given to help the physicians in their daily clinical practice.Patients under anti-platelet therapyPierre Albaladejo, Charles Marc Samama10.1016/j.bpa.2009.09.008Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-74150http://www.clinicalanaesthesiology.com/article/PIIS1521689609000718/abstract?rss=yesClinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. This practice is not supported by the literature, is unlikely to be of benefit and unnecessarily exposes patients to the risks of FFP. The role of FFP in reversing the effects of warfarin anticoagulation is dependent on the clinical context and availability of alternative agents. Although FFP is commonly transfused in patients with liver disease, this practice needs broad reconsideration. Adverse effects of FFP include febrile and allergic reactions, transfusion-associated circulatory overload and transfusion-related acute lung injury. The latter is the most serious complication, being less common with the preferential use of non-alloimmunised, male-donor predominant plasma. FP24 and thawed plasma are alternatives to FFP with similar indications for administration. Both provide an opportunity for increasing the safe plasma donor pool. Although prothrombin complex concentrates and factor VIIa may be used as alternatives to FFP in a variety of specific clinical contexts, additional study is needed.Perioperative coagulation management – fresh frozen plasmaDaryl J. Kor, James R. Stubbs, Ognjen Gajic10.1016/j.bpa.2009.09.007Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-75164http://www.clinicalanaesthesiology.com/article/PIIS1521689609000937/abstract?rss=yesPlatelets are active metabolising cells that are evolved for the tasks of haemostasis, inflammatory reactions and wound healing. When platelet products are stored in the blood bank a complex series of changes occur, leading to partial activation, up-regulation of inflammatory mediators, cellular morphology changes, loss of cell membrane lipids and micro-particle formation, as well as apoptosis. The resultant coagulation transfusion product has a number of potential expected side effects including fever, alloimmunisation, sepsis, thrombosis and transfusion-related acute lung injury. Of course, these events are occasional side effects yet they are some of the most common potential disasters of transfusion. Platelet transfusions in patients bleeding from thrombocytopaenia or severe platelet suppression will most likely benefit from a platelet transfusion. However, outcome data (controversial) have shown in some populations that platelet transfusions are associated with worse patient outcomes. Such associations may be due to the biologic changes that have occurred during storage, lack of HLA matching as well as other causes or it could be a mismatch of the platelet products to patient's needs (over-use). Platelets are administered in the surgical arena often due to ‘clinical judgement’, which errs on the side of, perhaps, too frequent use.Platelet transfusions: the science behind safety, risks and appropriate applicationsBruce D. Spiess10.1016/j.bpa.2009.11.001Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-76583http://www.clinicalanaesthesiology.com/article/PIIS1521689609000755/abstract?rss=yesUnexplained intra-operative coagulopathies continue to be a diagnostic and therapeutic dilemma. The pathophysiology behind unexplained intra-operative coagulopathies is of great variety and complexity (pre-existing coagulopathies, dilutional coagulopathy, interactions of medications, etc.). We have shown in prospective studies that patients undergoing elective surgery who develop ’unexplained' intra-operative bleeding have significantly less F. XIII per unit thrombin available at any point in time (i.e., also already preoperatively) than patients without such coagulopathies. The consequence is a significant loss of clot firmness associated with an increase in intra-operative blood loss. Thus, these patients have less cross-linking capacity to begin with, which explains their preoperatively increased fibrin monomer concentration. It is important to note that the acquired (or compared with the amount of thrombin generated ’relative') F. XIII deficiency in situations with surgical stress shows early clinical relevance (i.e., clinical manifestation occurs even with only mild-to-moderate deficiency); this differs from the experiences with patients with congenital F. XIII deficiency, where a pronounced deficiency must be present to have clinically significant (spontaneous) bleeding. Patients undergoing elective surgery and having increased preoperative fibrin monomer concentration (as a marker of decreased cross-linking capacity) are at risk for increased intra-operative blood loss. At least one proof-of-principle landmark study suggests that such patients benefit from treatment with F. XIII early intra-operatively. This new concept helps to explain the pathophysiology behind unexplained intra-operative coagulopathies and thus allows for corresponding treatment strategies.F. XIII in perioperative coagulation managementWolfgang Korte10.1016/j.bpa.2009.09.011Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-78593http://www.clinicalanaesthesiology.com/article/PIIS152168960900069X/abstract?rss=yesRecombinant activated factor VII (rFVIIa) is a haemostatic agent, which was originally developed for the treatment of haemophilia patients with inhibitors against factor FVIII or FIX. The efficacy of rFVIIa in preventing or stopping life-threatening bleeding for these patients has been demonstrated in several studies. Since the first report about the successful use of rFVIIa in a bleeding soldier in 1999, rFVIIa has gained popularity as an adjunct for the treatment of coagulopathy in a wide array of clinical conditions with serious or life-threatening bleeding. The number of case reports and case series documenting the successful use of rFVIIa as last resort to terminate uncontrollable bleeding has steadily grown.Conflicting results have been reported from various studies. Considering the lack of data and potential publication bias associated with case reports, this review summarises the clinical evidence of the efficacy and safety of rFVIIa in the perioperative period.Activated recombinant factor VII (rFVIIa)Oliver Grottke, Dietrich Henzler, Rolf Rossaint10.1016/j.bpa.2009.09.005Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-795106http://www.clinicalanaesthesiology.com/article/PIIS1521689609000780/abstract?rss=yesThis article provides an overview of the scientific evidence regarding the efficacy and safety of antifibrinolytic agents and desmopressin to reduce surgical blood loss. The synthetic derivatives of lysine are the only antifibrinolytics available in clinical practice since the withdrawal of aprotinin. There is evidence that the prophylactic use of lysine analogues is efficacious in reducing perioperative blood loss in cardiac and major orthopaedic surgery. The impact on exposure to blood transfusion is, however, variable. There is no evidence at present that they improve the overall outcome. Lysine analogues appear to be well tolerated in coronary artery bypass surgery, but less is known regarding their risk–benefit profile in special patient groups. Further studies are needed to elucidate the best compromise between dosing regimen, efficacy and safety in various clinical settings. Desmopressin may reduce excessive bleeding and transfusion requirements in some specific patient populations with acquired platelet dysfunction, but this needs to be validated in future studies.Pharmacological agents: antifibrinolytics and desmopressinYves Ozier, Lorenn Bellamy10.1016/j.bpa.2009.09.014Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7107119http://www.clinicalanaesthesiology.com/article/PIIS1521689609000688/abstract?rss=yesAs the life expectancy of our Western population progressively increases, so does the prevalence of cardiovascular disease and thus the use of antithrombotic drugs. The use of central neuraxial anaesthesia techniques in patients treated with these drugs is a major clinical problem as the presence of an impaired coagulation has been found to be the most important risk factor contributing to the formation of a spinal haematoma. The growing number of case reports of spinal haematoma has led many national societies of anaesthetists to come up with guidelines. This article presents an overview of current guidelines on the use of regional anaesthetic techniques in patients treated with various anticoagulants and also describes a possible strategy to deal with new antithrombotic drugs that have recently been introduced in some countries or will be shortly in others.Regional anaesthesia and anticoagulationErik Vandermeulen10.1016/j.bpa.2009.09.004Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7121131http://www.clinicalanaesthesiology.com/article/PIIS1521689609000767/abstract?rss=yesOne of the greatest disappointments associated with a successful surgical procedure is a thrombotic or thrombo-embolic complication in the postoperative period. Morbidity and mortality of the perioperative period are related, to a relevant degree, to perioperative thrombo-embolic events. Ranging from simple deep venous thrombosis to pulmonary embolism or arterial thrombosis, this class of complication invariably increases length of hospital stay or may result in mortality. The purpose of this review is to identify the procedures and patient populations noted to have thrombophilia in the postoperative period, link the changes in circulating and in situ haematological/biochemical substrates most likely responsible for morbidity, identify the clinical diagnostic modalities that detect recent/impending thrombosis and, lastly, consider the rational therapeutic approaches recommended for minimising postoperative thrombotic complications.Hypercoagulability in the perioperative periodVance G. Nielsen, Lars M. Asmis10.1016/j.bpa.2009.09.012Best Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7133144http://www.clinicalanaesthesiology.com/article/PIIS152168961000011X/abstract?rss=yesKeyword index10.1016/S1521-6896(10)00011-XBest Practice & Research Clinical Anaesthesiology 24, 1 (2010)2010-03-01Best Practice & Research Clinical Anaesthesiology2010-03-01241S1521-6896(10)X0002-7I1I1