Best practice & research. Clinical anaesthesiology
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With the expansion of ambulatory surgery in the Western world over the last 10 years, it has become increasingly important to identify patients at risk of perioperative complications and to use appropriate methods to decrease these risks. The confidential enquiry into perioperative deaths was one of the first national programmes instituted to identify patients at risk after the operation. Although the focus for this initial enquiry was on perioperative mortality, recent developments have increasingly focused on identification of perioperative morbid events. ⋯ Later, strategies are discussed which could reduce the perioperative general and cardiorespiratory risks in the ambulatory surgical patient. Many of these strategies are derived from the inpatient since appropriate data in outpatients are lacking. Future studies should thus focus on data derived from outpatients and prospective, randomized, double-blind studies in a large population of patients in order to first identify the patient at risk and subsequently to use drugs and techniques that reduce these perioperative risks.
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies for postoperative nausea and vomiting.
Significant improvement towards a better control of postoperative nausea and vomiting have been achieved in recent years. Today, we understand better who is likely to vomit or to be nauseous after surgery. Significant amounts of the huge literature on anti-emetic interventions have been systematically reviewed, critically appraised and quantitatively synthesized. ⋯ We also know which interventions have no worthwhile efficacy. A rational approach to postoperative nausea and vomiting includes three steps: identification of patients at risk, keeping the baseline risk low, and prophylactic administration of anti-emetics in those patients who are most likely to need them. For patients who are identified as high-risk patients, all measurements should be simultaneously initiated (multimodal anti-emesis).
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Best Pract Res Clin Anaesthesiol · Dec 2004
ReviewStrategies for prophylaxis and treatment for aspiration.
The absolute incidence of aspiration is difficult to define because of its relatively low occurrence and difficulty in diagnosis. The gastric volume predisposing to aspiration is larger than 30 ml. Fasting times for fluids have reduced; however, a large meal may require 9 hours of preoperative fasting. ⋯ The role of cricoid pressure in anaesthesia needs re-evaluation as radiological and clinical evidence suggest that it may be ineffective and may impede intubation and ventilation. Chemoprophylaxis does not reduce the severity of aspiration pneumonitis as gastric bile is unaffected by these agents and induces a worse pneumonitis than gastric acid. Patients may be discharged home 2 hours after aspirating provided they are clinically unaffected and have postoperative surveillance.
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Diabetes mellitus is now classified as either 'type 1' (failure of endogenous insulin production) or 'type 2' ('insulin resistance') and can be diagnosed if fasting blood glucose is >6.1 mmol/l (110mg/dl) on two separate occasions or there is unequivocal hyperglycaemia with acute metabolic decompensation or obvious symptoms. The prevalence of the disease is rising and may be as great as 12-14% in western populations aged over 40 years. ⋯ It is associated with increased perioperative mortality and morbidity. Evidence is now accumulating that intensive glycaemic monitoring and the administration of insulin infusions to achieve tight glycaemic control are associated with an improvement of both perioperative mortality and morbidity.
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Rapid atrial arrhythmias affect close to one million elderly Americans who undergo cardiac or non-cardiac operations annually and have been associated with prolonged hospital stays. In contrast, bradyarrhythmias or ventricular arrhythmias severe enough to require treatment occur in less than 1% of patients who undergo all types of surgery, including cardiac. ⋯ New approaches directed at prophylaxis and acute therapy of atrial arrhythmias are discussed, as are recommendations to prevent thromboembolic events. Practice and research agenda are proposed.