British journal of anaesthesia
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Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. ⋯ Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.
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Correct diagnostic management of perioperative hypersensitivity aims to identify the underlying mechanism(s), responsible culprit(s), and safe alternative drugs or techniques. Although drug provocation tests are considered the gold standard, diagnosis of perioperative hypersensitivity mainly relies on skin testing. Use of in vitro tests, such as quantification of specific immunoglobulin E antibodies, serum tryptase, and plasma histamine, as well as basophil activation tests is becoming widespread. ⋯ In this narrative review, we summarise the principles of these in vitro tests, and the possibilities and limitations when these tests are used for testing sensitivity to substances with a high risk of causing perioperative hypersensitivity. Hence, we focus on neuromuscular blocking agents, antibiotics, natural rubber latex, and opiates/opioids. The combination of multiple tests would allow diagnosis of perioperative hypersensitivity with the right balance of safety and accuracy.
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Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. ⋯ A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.
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Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. ⋯ EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.