Anesthesiology clinics
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Anesthesiology clinics · Mar 2015
ReviewPathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes.
Enhanced recovery pathways have been increasingly adopted into surgical specialties with the aim of reducing the stress response and improving the metabolic response to surgical insult. Enhanced recovery pathways encompass a large range of perioperative elements that together aim to restore a patient's gut function, mobility, function and well-being to preoperative levels as soon as feasible after major surgery. ⋯ This may not just have a benefit by reducing morbidity and mortality but also have an effect on long-term survival. There also may be additional benefits for patients with cancer.
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Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.
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Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. ⋯ Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.
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Regional anesthesia plays a key role in the treatment of patients with orthopedic trauma. Trauma-induced pain can be in multiple locations, severe, and can predispose the patient to other morbidities. Additional complications as a result of the overdependence on opioids as a primary pain therapy that can be minimized or avoided with the use of regional anesthesia. Both neuraxial and peripheral regional techniques in patients with orthopedic trauma should be incorporated into the patient care plan and recognized as an essential therapeutic intervention in the overall treatment of this unique patient population.
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Anesthesiology clinics · Dec 2014
ReviewWhich outcomes related to regional anesthesia are most important for orthopedic surgery patients?
An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.