Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2006
ReviewExcellent anaesthesia needs patient preparation and postoperative support to influence outcome.
Studies over many years have demonstrated that preoptimization and attention to appropriate perioperative care is associated with a substantial decrease in surgical mortality. This review discusses ways in which patient preparation and perioperative support can minimize surgical mortality and morbidity. ⋯ The provision of a high-quality service throughout the perioperative period is vital for a successful outcome. Patients need to be assessed well before major elective surgery to determine if they fall into a high-risk category. Some patients may benefit from a change in management. Postoperatively, critical-care support should be available backed by level 1 (enhanced ward) care with input from outreach or medical emergency teams 24 hours per day, seven days a week.
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Transfusion therapy in the intensive care unit is an ever-growing field, with new understanding of potential complications, new drug therapies to reduce the need for transfusion, and new additions in component therapy. In addition to the risks of sepsis, ABO blood group mismatch, and other complications associated with transfusion, the intensivist needs to be familiar with alternative therapies to minimize transfusion. ⋯ Recognizing early signs of transfusion-related acute lung injury may aid in the treatment and reporting of this entity. Realizing the mechanism and severity of immunosuppression associated with transfusion may alter transfusion triggers in the intensive care unit. rHuEPO and aprotinin are now being used with increasing frequency to increase red cell counts and minimize the need for transfusion. Recombinant factor FVIIa targets coagulation cascade activation which helps to reduce the number of units of blood products transfused in the actively bleeding patient.
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Ventilator-associated pneumonia remains an important topic (or subject) in the care of the critically ill. Issues related to ventilator-associated pneumonia are now particularly acute given the continued increase in rates of antimicrobial resistance seen in intensive care units. This review examines the latest literature in this area, including promising approaches to infection prevention and recently developed guidelines to aid clinicians in limiting, identifying and treating ventilator-associated pneumonia. ⋯ Recent studies have started to illuminate the full magnitude of the impact of ventilator-associated pneumonia in the intensive care unit and suggest potential measures for intervention. Hopefully, additional work will aid in eventual development of effective preventive, diagnostic and therapeutic strategies that can reliably improve patient outcomes.
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Curr Opin Anaesthesiol · Apr 2006
ReviewOperating room design and its impact on operating room economics.
Operating rooms are high-cost/high-revenue environments. In an era of rising costs and declining reimbursement, it is essential to optimize the effectiveness of the operating room suite, maximizing throughput of profitable cases while minimizing the costs of necessary, but unprofitable, procedures. ⋯ Redesigning perioperative systems can increase operating room throughput, but not all case mixes benefit from the required additional resources. Thus hospitals should choose judiciously if, and to what degree, high throughput environments are implemented. Once implemented, access to these environments can be used as an incentive for improved surgical performance.