Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Aug 2018
ReviewEndovascular thrombectomy in acute ischemic stroke: new treatment guide.
Recent randomized clinical trials (RCTs) have demonstrated strong efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions (LVO). SIESTA, AnSTROKE, GOLIATH showed no deleterious effects of general anesthesia on patient outcome after EVT compared with conscious sedation. DAWN and DEFUSE 3 are extending the time window for EVT up to 24 h in carefully selected patients. This review discusses the current literature on the rapidly expanding subject of endovascular stroke therapy and optimal anesthetic management. ⋯ Effective reperfusion with stent retriever technology, careful patient selection using perfusion imaging, and careful use of anesthetic technique affect outcome.
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Curr Opin Anaesthesiol · Aug 2018
ReviewMeasuring quality of recovery in perioperative clinical trials.
Perioperative studies increasingly report patient-centered outcomes, but few provide a valid, global measure of a patient's health status after surgery and anesthesia. This review considers three quality of recovery (QoR) scales. ⋯ The QoR Score, QoR-15, and QoR-40 are valid and recommended endpoints for perioperative clinical trials, and there is guidance as to what constitutes a minimal clinically important difference. These recovery scales are sensitive to a change in health status and, as numerical data, optimize statistical power when used in the design of a clinical trial. They are closely correlated with conventional measures of outcome such as analgesic consumption, pain scores, nausea and vomiting, and hospital stay. Although conventional measures may be considered patient-centered, each are incomplete by themselves. QoR scores provide a meaningful overall evaluation of a patient's recovery after surgery and anesthesia.
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Curr Opin Anaesthesiol · Aug 2018
ReviewCalculations of consciousness: electroencephalography analyses to determine anesthetic depth.
Electroencephalography (EEG) was introduced into anesthesia practice in the 1990s as a tool to titrate anesthetic depth. However, limitations in current analysis techniques have called into question whether these techniques improve standard of care, or instead call for improved, more ubiquitously applicable measures to assess anesthetic transitions and depth. This review highlights emerging analytical approaches and techniques from neuroscience research that have the potential to better capture anesthetic transitions to provide better measurements of anesthetic depth. ⋯ Up-and-coming techniques have the potential to better clinically define and characterize altered consciousness time points. Such new techniques used alongside traditional measures have the potential to improve depth of anesthesia measurements and enhance an understanding of how the brain is affected by anesthetic agents. However, new measures will be needed to be tested for robustness in real-world environments and on diverse experimental protocols.
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Curr Opin Anaesthesiol · Aug 2018
ReviewDo we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?
In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients. ⋯ A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.
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Nonoperating room anesthesia (NORA) and procedural services often are associated with dispersed geographic settings and small volumes of cases. These lead to scheduling challenges that, if not managed well, result in decreased patient and healthcare team satisfaction and reduced efficiency. This review describes recent studies and provides examples on how NORA scheduling issues have been addressed. ⋯ Many factors play a role in successful scheduling of NORA services. Increasing consolidation of services, the use of block scheduling, and leadership by anesthesiologists can help improve patient and healthcare team satisfaction and practice efficiencies.