Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2006
ReviewModern preoperative fasting guidelines: a summary of the present recommendations and remaining questions.
This chapter is complementary to the others in this volume focusing on preoperative fasting routines. In it we discuss some of the issues in need of more research to define best practice. One of these is the role of fasting in emergency patients. ⋯ Last but not least, new scientific evidence alone is not enough to change daily practice. Active implementation of new evidence is also needed. To improve perioperative care, anaesthesiologists, surgeons and the nursing staff must work together.
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Best Pract Res Clin Anaesthesiol · Sep 2006
ReviewThe resistance to changing guidelines--what are the challenges and how to meet them.
Bridging the gap between scientific evidence and its practical application is of the utmost importance in improving the quality of care and increasing patient safety. Guidelines based on evidenced-based medicine (EBM) have led to improved performances and better outcomes. However, even though scientific data are available, resistance to adopting evidence-based guidelines is still enormous. ⋯ Political, organizational, financial, cultural and scientific interests are regarded as being as important as the perception of patients and health workers. Strategies need to be planned which take account of the multidimensional character of quality of care and incorporate it at the various levels. The conclusion, therefore, is that we need to combine methods and tools to tailor our interventions to the patient's needs.
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Pulmonary aspiration of gastric contents in the perioperative phase is associated with increased postoperative morbidity and mortality. For the management of aspiration, differentiation between acid-associated aspiration pneumonitis and aspiration pneumonia as a consequence of a secondary bacterial contamination is of crucial importance. The incidence of aspiration in elective surgery is 1 per 2000-3000 anaesthesias in adults. ⋯ Cricoid pressure, as a non-evidence-based but clinically wide-spread method in the context of the prophylaxis of aspiration, is discussed critically. The main part deals with strategies to structure the management of aspiration by use of scientific concepts based on medical crisis management. For this, an algorithm based on current scientific investigations is presented.
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Best Pract Res Clin Anaesthesiol · Sep 2006
ReviewThe evidence base behind modern fasting guidelines.
Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents, thus decreasing the risk of regurgitation/aspiration. The objectives of the Cochrane report which are summarised in this paper, were to systematically review the effect of different preoperative fasting regimes (duration, type and volume of intake) on perioperative complications and patient wellbeing. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety ie. intraoperative gastric volume and pH. ⋯ Intake of fluids up to 90 min preoperatively had no impact on gastric contents but this was based on small numbers. In addition, permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Clinicians should evaluate this evidence for themselves and when necessary, adjust existing fasting policies.
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Pediatric fasting guidelines are intended to reduce the risk of pulmonary aspiration of gastric contents and facilitate the safe and efficient conduct of anesthesia. Recent changes in these guidelines, while assuring appropriate levels of patient safety, have been directed at improving the overall perioperative experience for infants, children, and their parents. ⋯ Shortened fasting periods for breast milk (3 hr), formula (4 hr) and light meals (6 hr) are supported by accumulated experience and an evolving literature that includes evidence of minimal gastric fluid volumes (GFVs) at the time of surgery. Ideal fasting intervals for children with disorders that may affect gastrointestinal transit have yet to be determined.