Explore NYSORA knowledge base for free:
Explore NYSORA knowledge base for free:
Hemorrhagic shock remains a leading cause of preventable mortality in trauma, demanding rapid and effective resuscitation strategies. Yet the optimal approach to volume replacement in this context remains controversial. Over the past two decades, clinical guidelines have moved markedly away from liberal fluid administration toward more restrictive resuscitation strategies, reflecting concerns over iatrogenic complications such as dilutional coagulopathy, hypothermia, acidosis, and organ dysfunction. The 2025 review by Markl-Le Levé et al. provides a timely synthesis of the evolving evidence, physiological rationale, and clinical controversies surrounding resuscitation fluid choice. It underscores the ongoing transition from aggressive crystalloid and colloid use to more targeted, physiologically grounded strategies based on patient-specific needs and pathophysiologic context. Methods This article is a narrative literature review synthesizing contemporary research, guideline recommendations (notably the 2023 European Trauma Guidelines), and key trials investigating fluid resuscitation modalities in trauma-associated hemorrhagic shock. It evaluates the efficacy and safety profiles of: Crystalloids (balanced vs. unbalanced) Synthetic colloids (hydroxyethyl starch, gelatin) Natural colloids (albumin) Blood products and plasma derivatives The review considers pathophysiological mechanisms such as the “lethal triad of trauma” (hypoperfusion, acidosis, coagulopathy), endothelial dysfunction, and trauma-induced coagulopathy (TIC), which heavily influence resuscitation efficacy and risks. The physiological basis: the lethal triad and trauma-induced coagulopathy At the heart of hemorrhagic shock lies the lethal triad—hypoperfusion, acidosis, and coagulopathy—which perpetuates a downward spiral of tissue injury, inflammation, and hemostatic failure. The review highlights the increasingly appreciated role of endotheliopathy and systemic inflammation in triggering trauma-induced coagulopathy (TIC), a condition that resists simple correction via volume expansion alone. TIC is driven by several overlapping mechanisms: Hypoperfusion-induced activation of the protein C pathway Hyperfibrinolysis and clotting factor depletion Platelet dysfunction and impaired thrombin generation Disruption of fibrin polymerization These insights necessitate a shift away from purely volumetric resuscitation targets toward strategies that also consider […]
August 26, 2025
Postoperative delirium (POD) is a frequent, preventable, and serious complication in surgical patients, particularly in older adults. The 2024 update of the European Society of Anaesthesiology and Intensive Care (ESAIC) guidelines brings crucial advancements in the understanding, prevention, and management of POD. What is postoperative delirium? POD is an acute neurocognitive disorder that typically occurs within the first few days after surgery. It is characterized by: Inattention Altered consciousness or disorganized thinking Fluctuating course POD is associated with: Longer hospital stays Higher complication rates Increased mortality and long-term cognitive decline Pathophysiology of POD POD arises from the interaction between preexisting patient vulnerabilities and surgical stressors that affect the brain. The updated guidelines highlight several key biological mechanisms. Major contributors include: Neuroinflammation triggered by surgery Blood-brain barrier disruption Mitochondrial dysfunction Neurotransmitter imbalances Preexisting cognitive impairment Cytokine storms and anesthetic influence Pharmacological vs. nonpharmacological interventions The new ESAIC guideline recommends a multimodal prevention approach. Below is a summary of interventions by category: Evidence-based strategies: what works best? Strongly recommended Preoperative risk screening Multicomponent nonpharmacological bundles Team-based care planning Dexmedetomidine use (with caution) in selected patients Not recommended for routine use Haloperidol or other neuroleptics Cholinesterase inhibitors Routine biomarker screening Specific anesthesia types (general vs regional) How to prevent POD: step-by-step guide 1. Screen preoperatively Use tools like MMSE, MOCA, or Mini-Cog. Assess: Cognitive function Frailty Comorbidities Medication list Nutritional status 2. Inform and coordinate the team Document POD risk clearly in medical records and share with: Anaesthesiologists Surgeons Nurses Geriatric teams 3. Implement prevention bundles Focus on: Reorientation strategies Sleep hygiene (quiet room, eye masks) Early mobilisation Nutrition support Family involvement 4. Monitor for POD Use validated tools (CAM-ICU, Nu-DESC) daily for 3 days post-op, starting in recovery. Key recommendations Risk screening: Mandatory for patients ≥60 years Cognitive tools: Mini-Cog, MOCA, ACE-R […]
August 25, 2025
Cardiac arrest during surgery or the perioperative period is a critical event with devastating consequences. Mortality remains exceptionally high, between 56% and 65%, even when conventional advanced cardiovascular life support (ACLS) protocols are promptly applied. One emerging innovation that offers renewed hope is extracorporeal cardiopulmonary resuscitation (ECPR), which uses extracorporeal membrane oxygenation (ECMO) to sustain circulation and oxygenation during cardiac arrest unresponsive to standard resuscitation efforts. In their May 2024 clinical focus review, Pande et al. (Anesthesiology) present a comprehensive analysis of the role of ECPR in adult perioperative settings. Their findings help anesthesiologists and perioperative physicians navigate this complex, resource-intensive intervention and clarify when and how ECPR can transform a catastrophic arrest into a survivable event. Why this topic matters Conventional CPR fails to achieve adequate organ perfusion in many patients, particularly during prolonged resuscitation. ECPR can restore near-normal perfusion, buying time for teams to identify and reverse the underlying cause of arrest. The perioperative setting offers unique advantages: witnessed arrests, immediate access to clinicians, and often readily available ECMO resources. What is extracorporeal CPR? ECPR involves the rapid deployment of venoarterial ECMO during a cardiac arrest when return of spontaneous circulation (ROSC) is not achieved with conventional CPR. This system temporarily: Drains venous blood (typically via femoral vein), Oxygenates it externally, Pumps it back into the arterial circulation (typically via femoral artery), Providing continuous oxygenated blood flow to vital organs. Unlike CPR, which delivers ~25% of normal cardiac output, ECMO can provide full end-organ perfusion, reducing the risk of ischemic brain and organ injury. Indications: when to consider ECPR? ECPR should be considered when the cardiac arrest is witnessed, the cause is potentially reversible, and conventional CPR fails to restore circulation within 10–20 minutes. Key indicators include: Neurologic viability No-flow time < 5 minutes: time from arrest to […]
August 22, 2025
