Anaesthesia
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Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.
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'Enhanced recovery after surgery' protocols implement a series of peri-operative interventions intended to improve recovery after major operations, one aspect of which is fluid management. The pre-operative goal is to prepare a hydrated, euvolaemic patient by avoiding routine mechanical bowel preparation and by encouraging patients to drink clear liquids up to two hours before induction of anaesthesia. ⋯ The postoperative goal is eating and drinking without intravenous fluid infusions. Postoperative oliguria should be expected and accepted, as urine output does not indicate overall fluid status.
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While specialist pre-operative assessment is not new, its focus has evolved in response to more operations and changes in the surgical population. Patients are older and have more long-term medical comorbidities. ⋯ Pre-operative clinics have a central role in shared decision-making, coordinating and planning care before, during and after surgery, including rehabilitation and discharge planning. Multiple specialties need to work together to deliver quality patient-centred care.
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Pulmonary complications are a major cause of peri-operative morbidity and mortality, but have been researched less thoroughly than cardiac complications. It is important to try and predict which patients are at risk of peri-operative pulmonary complications and to intervene to reduce this risk. Anaesthetists are in a unique position to do this during the whole peri-operative period. Pre-operative training, smoking cessation and lung ventilation with tidal volumes of 6-8 ml.kg(-1) and low positive end-expiratory pressure probably reduce postoperative pulmonary complications.
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Randomized Controlled Trial Comparative Study
A comparison of single dose dexmedetomidine with propofol for the prevention of emergence delirium after desflurane anaesthesia in children.
Emergence delirium is a common problem in children recovering from general anaesthesia. We performed a study comparing emergence characteristics in 100 patients who were randomly allocated to receive either 0.3 μg.kg(-1) dexmedetomidine, 1 mg.kg(-1) propofol or saline 0.9% and undergoing infra-umbilical surgery. ⋯ In the dexmedetomidine group, sedation occurred in 62.5% of children at 10 min after transfer to the recovery area, compared with 44.4% in the propofol group and 12.5% in the control group (p = 0.010). We conclude that dexmedetomidine significantly reduced the incidence of emergence delirium but this was at the expense of a greater incidence of sedation in the recovery period.