Anesthesia and analgesia
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Anesthesia and analgesia · Apr 2018
Global Surgery System Strengthening: It Is All About the Right Metrics.
Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. ⋯ The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.
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Anesthesia and analgesia · Apr 2018
ReviewPostpartum Tubal Sterilization: Making the Case for Urgency.
The parturient who requests postpartum sterilization has given consideration to and has made decisions regarding this aspect of her medical care long before her delivery. She arrives at parturition expecting the postpartum procedure to be performed as intended. The American Congress of Obstetricians and Gynecologists has reaffirmed its opinion that postpartum sterilization is an urgent procedure, owing to the safety and superior effectiveness of tubal sterilization via minilaparotomy in the immediate postpartum period, and the adverse consequences for mothers, babies, and society when the procedure is not actualized as desired and intended. ⋯ Reasons for failure to complete abound and include inadequate resources or inavailability of necessary personnel; obstetrician reluctance due to concerns for patient regret in younger women or medical comorbidities; barriers related to provision of obstetric care in a religiously affiliated hospital, or incomplete, improperly completed, or unavailable original federal consent forms among Medicaid-insured women. The federal requirement to wait 30 days after signing informed consent, and to retain the original signed document to be physically verified at time of the procedure, serves as a significant source of health care disparity for Medicaid-dependent mothers. This article reviews these larger issues of maternal health and comprehensive maternal care to broaden the anesthesiologist's appreciation of major benefits and potential risks of postpartum sterilization, including long-term effects, to promote an evidence-based, informed, and proactive role in delivering equitable, safe, and optimal care for these patients.
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Anesthesia and analgesia · Apr 2018
ReviewFatigue Risk Management: The Impact of Anesthesiology Residents' Work Schedules on Job Performance and a Review of Potential Countermeasures.
Long duty periods and overnight call shifts impair physicians' performance on measures of vigilance, psychomotor functioning, alertness, and mood. Anesthesiology residents typically work between 64 and 70 hours per week and are often required to work 24 hours or overnight shifts, sometimes taking call every third night. Mitigating the effects of sleep loss, circadian misalignment, and sleep inertia requires an understanding of the relationship among work schedules, fatigue, and job performance. ⋯ We then propose countermeasures that have been implemented to mitigate the effects of fatigue and describe how training programs or practice groups who must work overnight can adapt these strategies for use in a hospital setting. Countermeasures include the use of scheduling interventions, strategic naps, microbreaks, caffeine use during overnight and extended shifts, and the use of bright lights in the clinical setting when possible or personal blue light devices when the room lights must be turned off. Although this review focuses primarily on anesthesiology residents in training, many of the mitigation strategies described here can be used effectively by physicians in practice.
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Anesthesia and analgesia · Apr 2018
Comparative StudyAge Does Not Affect Metoprolol's Effect on Perioperative Outcomes (From the POISE Database).
Perioperative β-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefits but more harms associated with β-blockade due to a normal effect of aging, that of a reduced resting heart rate. The tested hypothesis was that the effect of perioperative β-blockade is more significant with increasing age. ⋯ The effect of perioperative β-blockade on the major outcomes studied did not vary with age. Resting heart rate decreases slightly with age. Our data do not support a recommendation for the use of perioperative β-blockade in any age subgroup to achieve benefits but avoid harms. Therefore, current recommendations against the use of β-blockers in high-risk patients undergoing noncardiac surgery apply across all age groups.
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Anesthesia and analgesia · Apr 2018
Patient Survey of Referral From One Surgeon to Another to Reduce Maximum Waiting Time for Elective Surgery and Hours of Overutilized Operating Room Time.
Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients' understanding of treatment options. We consider shared decision making applied to case scheduling, since implementation would reduce labor costs. ⋯ Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients' individual preferences (ie, patient-centered).