Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2015
ReviewSafety-II and resilience: the way ahead in patient safety in anaesthesiology.
Anaesthesiology is a specialty with a remarkable track record regarding improvements in safety. Nevertheless, modern healthcare poses increasing demands on quality and outcome: more complexity, more patients with increasing risk-factors, more regulation from society concerning quality and outcome and finally more demand of the stakeholders for efficiency. This leads us to ask the question if our traditional way of handling 'risk' and 'safety' will stand the challenges of the future? ⋯ We are well advised to consider adapting these modern concepts of 'resilience' and 'safety-II' thinking when we want to substantially improve patient safety in anaesthesiology.
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The increasing request for procedural sedation will create in the upcoming future the need for a specific training in delivering care to patients in a continuum of sedation, whose effects and adverse events are unpredictable. The main debate in the past years has been focused on using drugs that could have few adverse effects and could be considered well tolerated when administered by a nonanaesthesiologist. Propofol remains the most used drug for procedural sedation, but given its side-effects, its administration is limited and suggested only when an anaesthesiologist is available. The main studies recently appearing in the literature are focusing on the use of alternative drugs such as dexmedetomidine, remifentanil, fospropofol, ketofol and remimazolam. The current study is an overview of the different fields of procedural sedation, describing the evidence from the published studies and some upcoming studies. ⋯ Recent studies on procedural sedation are still debating on the use of propofol by nonanaesthesiologists and are exploring the use of other sedatives and analgesics. The main goal in the future should be to have a clear curriculum on the role of the 'sedationalist' outside the operating room.
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Orphan diseases certainly have a challenging impact on anesthesia practice. Low prevalence by definition leads to a profound lack of evidence-based medical knowledge, and anesthetists usually cannot rely on personal experience for handling this unique group of patients. Then again, more than 7000 known orphan diseases are estimated to affect 5% of the general population in total. Therefore, it is imperative to have a universally valid approach to anesthesia for orphan diseases. ⋯ Thanks to fast growing resources of knowledge, well tolerated and patient-oriented anesthesia is possible in spite of the inherent challenges of orphan diseases. We invite anesthetists to adapt, modify and improve our proposed structured approach to orphan anesthesia in the context of their daily practice.
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The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted. ⋯ Ambulatory anesthesia's popularity continues to rise and anesthetic techniques will continue to morph and adapt to the needs of patients seeking ambulatory surgery. Alterations in already existing medications are promising as these modifications allow for quicker recovery from anesthesia or minimization of the already known undesirable side-effects. PONV, pain, obstructive sleep apnea, and chronic comorbidities (hypertension, cardiac disease, and diabetes mellitus) are perioperative concerns in ambulatory settings as more patients are safely being treated in ambulatory settings. Regional anesthesia stands out as a modality that has multiple advantages to general anesthesia, providing a minimal recovery period and a decrease in postanesthesia care unit stay. The implementation of the Affordable Healthcare Act specifically affects ambulatory settings as the demand and need for patients to have screening procedures with anesthesia. The question remains what the best strategy is to meet the needs of our future patients while preserving economically feasibility within an already strained healthcare system.
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Curr Opin Anaesthesiol · Dec 2015
ReviewWrong-site regional anesthesia: review and recommendations for prevention?
Wrong-site regional anesthetic procedures are considered never events. The purpose of this review is to describe the phenomenon of wrong-site regional anesthetic blocks and identify preventive strategies. ⋯ Preoperative site verification and surgical site marking are mandatory. A time-out should occur immediately before any invasive procedure. Confirming the correct patient and block site with a time-out should occur immediately before all regional anesthetic procedures. If more than one block is performed on one patient, it is recommended that time-out be repeated each time the patient position is changed or separated in time or performed by a different team. The anesthetic team should uniformly implement robust guidelines and checklists to reduce the occurrence of wrong-site regional anesthetic procedures.