British journal of anaesthesia
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Surgery during pregnancy is complicated by the need to balance the requirements of two patients. Under usual circumstances, surgery is only conducted during pregnancy when it is absolutely necessary for the wellbeing of the mother, fetus, or both. Even so, the outcome is generally favourable for both the mother and the fetus. ⋯ It is not known whether these considerations affect the human fetus but studies are underway. Given the general considerations of avoiding fetal exposure to unnecessary medication and potential protection of the maternal airway, regional anaesthesia is usually preferred in pregnancy when it is practical for the medical and surgical condition. When surgery is indicated during pregnancy maintenance of maternal oxygenation, perfusion and homeostasis with the least extensive anaesthetic that is practical will assure the best outcome for the fetus.
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Many anaesthesia practitioners caring for patients with a cardiac implantable electronic device (CIED) lack the knowledge, experience, and requisite programming devices to independently manage these patients perioperatively. A recently updated ASA task force Practice Advisory presents expert opinion regarding the perioperative management of patients with CIEDs, and the Heart Rhythm Society (HRS) recently published a consensus statement on this subject in collaboration with the ASA, American Heart Association (AHA), and Society of Thoracic Surgeons (STS). The main intent of these documents is to provide recommendations that promote safe management of patients with CIEDs throughout the perioperative period and reduce the likelihood of adverse outcomes. ⋯ In emergent situations, however, or when there is no time for the requisite consultations, and in practice settings where the suggested multidisciplinary approach is simply not feasible, the anaesthesia team must still provide effective, safe perioperative management. Thus, all anaesthesiologists should become familiar with the basics of the current CIED technology and the essential tenets of perioperative CIED management. This review discusses relevant advances in CIED technology and practical perioperative management as outlined in the 2011 ASA Practice Advisory and HRS consensus statement.
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The actual incidence of neurological dysfunction resulting from haemorrhagic complications associated with neuraxial block is unknown. Although the incidence cited in the literature is estimated to be <1 in 150,000 epidural and <1 in 220,000 spinal anaesthetics, recent surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increases with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard unfractionated heparin or low molecular weight heparin). ⋯ Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal haematoma. Vigilance in monitoring is critical to allow early evaluation of neurological dysfunction and prompt intervention. An understanding of the complexity of this issue is essential to patient management.
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Summary While complex physiological mechanisms exist to regulate and optimize tissue oxygenation under various conditions, clinical and experimental evidence indicates that anaemia, unchecked, is associated with organ injury and unfavourable outcomes. More data (especially from human studies) are needed to answer questions regarding the optimal approaches to the treatment of acute and chronic anaemia. Meantime, allogeneic blood transfusions remain the most common treatment, particularly in surgical/trauma patients and those with moderate-to-severe anaemia. ⋯ Further characterization of the mechanisms of injury is needed to appropriately balance these risks and to develop novel treatment strategies that will improve patient outcomes. Here, we present the current understanding of the physiological mechanisms of tissue oxygen delivery, utilization, adaptation, and survival in the face of anaemia and current evidence on the independent (and often, synergistic) deleterious impact of anaemia and transfusion on patient outcomes. The risks of anaemia and transfusion in the light of substantial variations in transfusion practices, increasing costs, shrinking pool of donated resources, and ambiguity about actual clinical benefits of banked allogeneic blood demand better management strategies targeted at improving patient outcomes.
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In recent decades, a number of studies have attempted to determine whether regional anaesthesia offers convincing benefits over general anaesthesia. However, today we interpret meta-analyses more carefully, and it remains unclear whether regional anaesthesia reduces mortality. ⋯ Recent developments in technical aspects of regional anaesthesia have the potential to provide significant advantages for many patients in all age groups. Moreover, studies focusing on specific outcomes have shown benefits for regional anaesthesia used for surgery and postoperative analgesia.