Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2017
ReviewPreoperative evaluation and preparation of the morbidly obese patient.
This review aims to familiarize with the most current findings regarding preoperative evaluation and preparation of morbidly obese patients prior to elective, noncardiac surgery. In the light of the increasing number of surgical patients being morbidly obese, the knowledge of evidence-based preoperative evaluation strategies is profound for a rational approach. ⋯ Synthesis of proper medical history-taking and physical examination as well as detailed search for obstructive sleep apnea and metabolic syndrome are key components of preoperative evaluation. Further testing should be based on the findings of these steps and comprise the cardiac risk of the surgical procedure.
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Curr Opin Anaesthesiol · Feb 2017
ReviewPrevention of cardiac surgery-associated acute kidney injury.
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a frequently occurring complication. It carries the risks of increasing mortality and development of chronic kidney disease. The complex pathophysiologic mechanisms still remain unexplained to a large extent. As a result, there is a considerable lack of sufficient therapeutic strategies with renal replacement therapy still representing the cornerstone for the treatment of severe AKI. ⋯ The identification of high-risk patients for AKI and the adherence to the Kidney Disease: Improving Global Outcomes guidelines constitute the mainstays in the management of CSA-AKI. It is of paramount importance to always maintain a sufficient perfusion pressure throughout the perioperative period. In patients at high risk, the use of new biomarkers and remote ischemic preconditioning should be considered.
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Despite marked improvements in perioperative outcomes, esophagectomy continues to be a high-risk operation associated with significant morbidity and mortality. Progress has been achieved through evidence-based changes in preoperative optimization, intraoperative ventilation strategies, fluid therapy, and analgesia, as well as expedited postoperative recovery pathways. This review will summarize the recent literature on the anesthetic management of patients undergoing esophageal resection. ⋯ The morbidity and mortality after esophagectomy remains high despite significant improvements over the last decades. Enhanced recovery pathways appear promising in achieving further marginal gains but at present are lacking large scale, prospective, multicenter evidence.
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Curr Opin Anaesthesiol · Feb 2017
ReviewSpectrum of postoperative complications in pulmonary hypertension and obesity hypoventilation syndrome.
The purpose of this review is to identify chronic pulmonary conditions which may often not be recognized preoperatively especially before elective noncardiac surgery and which carry the highest risk of perioperative morbidity and mortality. ⋯ Pulmonary hypertension is a well recognized risk factor for postoperative complications after cardiac surgery but the literature surrounding noncardiac surgery is sparse. Pulmonary hypertension was only recently classified as an independent risk factor for postoperative complications in the American Heart Association/American College of Cardiology Foundation Practice Guideline for noncardiac surgery. Spinal anesthesia should be avoided in most surgeries on patients with pulmonary hypertension because of it's rapid sympatholytic effects. The presence of significant right ventricle dysfunction and marked hypoxemia should prompt re-evaluation of the need for elective surgery. Obesity hypoventilation syndrome is even harder to recognize preoperatively as arterial blood gases are generally not obtained prior to elective noncardiac surgery. Amongst patients with obstructive sleep apnea this group of patients carries much higher risk of postoperative respiratory and congestive heart failure.
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Enhanced recovery after surgery (ERAS) methodology has demonstrated consistent benefits in patients undergoing colorectal, urological and thoracic surgeries. Principles of these protocols and their advantages are expected to extend into other surgical specialties such as bariatric surgery. In this review, we summarize the components of ERAS protocols for bariatric surgery and present the evidence on the emerging role of ERAS principles in obese patients. ⋯ ERAS for bariatric surgery is in its early phase. Nevertheless, literature supports its role in improving perioperative outcomes compared with conventional care in this scenario. Evidence-based protocols, multidisciplinary teamwork and meticulous audit seem to be the key factors for success in ERAS methodology.