PubMed · 4415104
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J P Woodcock. 1974. Plethysmography.. https://pubmed.ncbi.nlm.nih.gov/4415104/
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Multidetector row CT is a feasible diagnostic tool in pre- and postoperative liver partial transplantation. We can assess vascular anatomy and liver parenchyma as well as volumetry, which provide useful information for both donor selection and surgical planning. Disorders of the vascular and biliary systems are carefully observed in recipients. In addition, we evaluate liver regeneration of both the donor and the recipient by serial volumetry. We present how multidetector row CT with state-of-the-art three-dimensional volume renderings may be used in right lobe liver transplantation.
Since the beginning of modern anesthesia, in 1846, the anesthetist has relied on his natural senses to monitor the patient, aided more recently by simple technical devices such as the stethoscope. There has been a tremendous increase in the availability of monitoring devices in the past 30 years. Modern technology has provided a large number of sophisticated monitors and therapeutic instruments, particularly in the past decade. Most of these techniques have enhanced our understanding of the mechanism of the patients' decompensation and have helped to guide appropriate therapeutic interventions. As surgery and critical care medicine have developed rapidly, patient monitoring capability has become increasingly complex. The most important aspect in monitoring the critically ill patient is the detection of life-threatening derangements of vital functions. Aggressive marketing strategies have been promoted to monitor almost every aspect of the patient's status. However, these strategies are only telling us what is possible; they do not tell us whether they enhance patient safety, improve our therapy, or even improve patient outcome.
BACKGROUND: Proximal Femoral Fracture (PFF) or 'hip fracture' is a frequent injury, and adverse outcomes are common. Many patients are elderly, with significant comorbidity. Several factors suggest the importance of developing appropriate techniques to optimize intravascular fluid volume. These may include protocols that enhance the efficacy of clinicians' assessments, invasive techniques such as oesophageal Doppler or central venous pressure monitoring, or advanced non-invasive techniques such as plethysmographic pulse volume determination. OBJECTIVES: To determine the optimal method of fluid volume optimization for adult patients undergoing surgical repair of hip fracture. Comparisons of fluid types (e.g. crystalloid vs. colloid) or of blood transfusion strategies or of other pharmacological interventions (e.g. inotropes) are not considered in this review. SEARCH STRATEGY: Randomized controlled trials (RCTs) since 1985 were identified by searching MEDLINE, EMBASE, the Cochrane Library, the Cochrane Anaesthesia Group's specialized Controlled Trials Register and bibliographies of retrieved articles. Relevant journals and conference proceedings were handsearched. SELECTION CRITERIA: RCTs comparing a fluid optimization intervention with normal practice (control) or with another fluid optimization intervention, in patients following PFF undergoing surgery of any type under anaesthesia of any type. DATA COLLECTION AND ANALYSIS: Searches and exclusion of clearly irrelevant articles were performed by one reviewer. Two reviewers examined independently the remaining studies, extracting study quality and results data. A wide range of short- and long-term outcome data was sought. Study quality was assessed using a ten-point instrument and studies were excluded if they did not meet the study criteria or if results were likely to be biased. Due to a lack of consistency in reporting, combination of data was not generally possible. MAIN RESULTS: Searches identified only four trials, of which two studies, randomizing a total of 130 patients, were of adequate quality and addressed the review question. Both studies were of invasive advanced haemodynamic monitoring during the intraoperative period only. One study randomized patients to 'normal care' or optimization using oesophageal Doppler; the second study randomized patients to 'normal care', oesophageal Doppler or central venous pressure monitoring. In each study, invasive monitoring led to a significant increase in volume of fluid infused and a reduction in length of hospital stay. The pooled Peto odds ratio for in-hospital fatality was 1.44 (95% confidence interval 0.45-4.62). Neither study followed patients beyond hospital discharge or assessed functional outcomes (for example return to previous accommodation). No serious complications were reported to be directly attributable to the monitoring interventions. There were no studies of protocol-guided fluid optimization or of advanced non-invasive techniques. REVIEWER'S CONCLUSIONS: Invasive methods of fluid optimization during surgery may shorten hospital stay, but their effects on other important, patient-centred, longer-term outcomes are uncertain. An adverse effect on fatality cannot be excluded. Other fluid optimization techniques have not been evaluated. The lack of randomized studies of adequate quality addressing this important question is disappointing given the high incidence and frequently adverse outcome of PFF. More research is needed.