Current opinion in anaesthesiology
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Although sedation traditionally has been regarded as an easy, straight forward and simple variety of general anaesthesia; the trends are to make sedation more sophisticated and dedicated. Also to have a critical look at old dogmas, as they are usually derived from the practice of general anaesthesia. Safety always has to be first priority, especially as the practice grows out of traditional theatres and frequently are being practiced by nonanaesthetic personnel. ⋯ Procedural sedation deserves to have high degree of attention for further developments, both from a scientific and pragmatic point of view, as the practice is very diversified and growing.
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Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. ⋯ Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with reduced opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission.
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The purpose of this article is to review the use of total intravenous anaesthesia (TIVA) in ambulatory care. ⋯ Review of recent evidence of TIVA's use in ambulatory surgery and summary of new international guidelines on its use.
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Curr Opin Anaesthesiol · Dec 2019
ReviewOffice-based anesthesia: an update on safety and outcomes (2017-2019).
Although both cost and patient preference tend to favor the office-based setting, one must consider the hidden costs in managing complications and readmissions. The purpose of this review is to provide an update on safety outcomes of office-based procedures, as well as to identify common patient-specific factors that influence the decision for office-based surgery or impact patient outcomes. ⋯ Overall, anesthesia and surgery in the office is becoming increasingly safe. Recent data suggest that the improved safety in the office-based setting is attributable to proper patient selection. Anesthesiologists play a critical role in prescreening eligible patients to ensure a safe and productive process. Patients treated in the office seem to be selected based on their low risk for complications, and our review reflects this position.
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Curr Opin Anaesthesiol · Dec 2019
ReviewPharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery.
The present review aims to propose pharmacological strategies to enhance current clinical practices for analgesia in ambulatory surgical settings and in the context of the opioid epidemic. ⋯ These strategies must combine three key components when not contraindicated: regional/local analgesia, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). Adjuvants such as gabapentinoids, N-methyl-D-aspartate receptor modulators, glucocorticoids, α2-adrenergic receptor agonists, intravenous lidocaine might be added to the initial multimodal strategy, however, caution must be used regarding their side effects and risks of delaying recovery after ambulatory surgery. Weaker opioids (e.g. oxycodone, hydrocodone, tramadol) could be used rather than more powerful ones (e.g. morphine, hydromorphone, inhaled fentanyl, sufentanil). This, combined with education about postoperative weaning of opioids after surgery must be done in order to avoid long-term reliance of these drugs.