Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewPharmacology in the elderly and newer anaesthesia drugs.
In developed countries, a growing proportion of patients presenting for anesthesia and surgery are elderly. Despite this, and the fact that aging is known to be associated with alterations in drug pharmacokinetics and dynamics, there is little detailed information about the impact of aging on the pharmacology of commonly used anesthetic agents. ⋯ Also, an overview of up-to-date PK-PD modeling concepts and their usefulness and limitations in modern anesthesiologic practice with respect to the elderly population is given. Finally, newer agents such as sugammadex, remifentanyl, ropivacaine and desflurane are discussed in detail with emphasis on current evidence concerning dosing, safety and efficacy of their use in the elderly.
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Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. ⋯ Evidence for the long term effects of perioperative complications adds further importance to minimizing perioperative complications. Newer approaches in patient care, particularly co-management during the postoperative phase by different specialities are emerging. Managing high-risk patients should also be enhanced with greater surveillance and more rapid and appropriate response; ensuring we do not fail to rescue our patients.
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Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewAdvance directives, perioperative care and end-of-life planning.
It is ethically and legally important, when providing care to our patients, to respect their autonomy and dignity, to act in their best interests and avoid doing harm. Advance care planning is essential to achieving this by giving patients the opportunity to tell us what they would want us to do if they became seriously unwell and could no longer communicate their wishes. ⋯ There is an increasing focus on improving end-of-life care, including the prevention of suffering, making earlier and wiser end-of-life decisions about the appropriateness of treatment and improving communication with patients and families. New awareness of the poor outcomes from cardiopulmonary resuscitation (CPR) is catalysing reassessment of the appropriateness of this intervention.