Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2019
ReviewAnaesthetic considerations in nonagenarians and centenarians.
The ageing population is a global public health issue and we can expect to encounter more and more older patients requiring anaesthetic care. Age itself is no longer the sole reason for declining a patient for anaesthesia and surgery. Undoubtedly, managing patients at the extremities of age is challenging and demanding, not only because of multiple comorbidities, but also the poorer functional status, frailty and decline in general well being that must be managed during the perioperative journey. In this article, we will focus on three important aspects of anaesthetic care for this patient group, namely, comorbidity, frailty and perioperative cognitive dysfunction; and give recommendations on how anaesthetists should tackle these aspects for the 'older old' and the 'oldest old', based on current best evidence. ⋯ Comorbidity, frailty and perioperative cognitive dysfunction are significant perioperative concerns specific to elderly patients and clearly associated with adverse outcomes after surgery. These anaesthetic concerns should be anticipated and properly managed through the perioperative pathway so that their potential complications can be mitigated.
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Curr Opin Anaesthesiol · Dec 2019
ReviewRecovery and discharge criteria after ambulatory anesthesia: can we improve them?
Day surgery coming and leaving hospital day of surgery is growing. From minor and intermediate procedure performed on health patient, day surgery is today performed on complex procedures and elderly patient and on patients with comorbidities. Thus, appropriate discharge assessment is of huge importance to secure safety and quality of care. ⋯ Discharge following day surgery must be based on appropriate assessment of stable vital signs and reasonable resumption of activity of daily living performance. Rapid discharge must not jeopardize safety. Classic discharge criteria are still basis for safe discharge, adding a structured discharge checklist facilitates safe discharge.
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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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Curr Opin Anaesthesiol · Dec 2019
ReviewBenefits and harms of increased inspiratory oxygen concentrations.
The topic of perioperative hyperoxia remains controversial, with valid arguments on both the 'pro' and 'con' side. On the 'pro' side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the 'con' side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries. ⋯ The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation.
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In an unconscious patient, there can be significant challenges to monitoring nociception and proper dosing of analgesic medications. The traditional measures of intraoperative nociception have poor sensitivity and specificity with little predictive value in postoperative outcomes such as postoperative pain, opioid-induced side effects, length of stay or incidence of opioid use disorder. To date, several monitoring modalities are in development to establish objective measures of the balance between nociception and analgesia with the goal of guiding anesthesiologists and improve patient outcomes. In this review, some of the most promising monitoring modalities are discussed with the most recent findings. ⋯ Recent evidence points to promising efficacy for these monitoring modalities; however, this field is in its infancy. More investigation is required to demonstrate differences in outcome compared with traditional care, and these differences need to be of sufficient import to achieve widespread adoption.