Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2006
ReviewBenefits and harms of perioperative beta-blockade.
Cardiac events in patients undergoing surgery may have serious consequences for both short- and long-term postoperative prognosis. Recently conducted trials have not demonstrated beneficial effects of perioperative beta-blockade, although originally small trials with methodological flaws did suggest this. ⋯ The largest observational study performed suggests that perioperative beta-blockade is associated with higher mortality in patients with low cardiac risk or diabetes, and with lower mortality in patients with high cardiac risk undergoing non-cardiac surgery. Larger randomized trials are needed to determine dosage, optimal duration, and safety of therapy, and to identify populations in whom-and how-perioperative beta-blockade may be beneficial.
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Best Pract Res Clin Anaesthesiol · Jun 2006
Review Comparative StudyRegional anaesthesia versus general anaesthesia, morbidity and mortality.
The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. ⋯ This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.
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The aim of this chapter is to focus on evidence-based health economics in anaesthesia. More and more, requests for additional facilities will have to be based on detailed arguments supported by 'hard evidence' as to the gain to be expected from the patient's angle and the cost. ⋯ This chapter shows how to bring economic evaluation and systematic review together, and how to use such evaluations in the clinical setting. It shows how economics can be used to broaden the evidence base for a more efficient and equitable health policy, and sets a future research agenda for this challenging area of work in Cochrane reviews dealing with anaesthesia topics.
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Perioperative fluid therapy is the subject of much controversy, and the results of the clinical trials investigating the effect of fluid therapy on outcome of surgery seem contradictory. The aim of this chapter is to review the evidence behind current standard fluid therapy, and to critically analyse the trials examining the effect of fluid therapy on outcome of surgery. The following conclusions are reached: current standard fluid therapy is not at all evidence-based; the evaporative loss from the abdominal cavity is highly overestimated; the non-anatomical third space loss is based on flawed methodology and most probably does not exist; the fluid volume accumulated in traumatized tissue is very small; and volume preloading of neuroaxial blockade is not effective and may cause postoperative fluid overload. ⋯ Without evidence of the existence of a non-anatomical third space loss and ineffectiveness of preloading of neuroaxial blockade, 'restricted intravenous fluid therapy' is not 'restricted', but rather avoids fluid overload by replacing only the fluid actually lost during surgery. The trials of different fluid volumes administered during outpatient surgery confirm that replacement of fluid lost improves outcome. Based on current evidence, the principles of 'restricted intravenous fluid therapy' are recommended: fluid lost should be replaced and fluid overload should be avoided.
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Preoperative assessment is a complex and multidisciplinary task. It encompasses surgical and anaesthesia assessment, preoperative testing, preparation of patients for surgery, and obtaining consent to the surgery. The scope of this chapter is to review the available evidence on anaesthesia preoperative evaluation (who, when and how to conduct it) and its relevance to clinical practice, and to indicate areas for future research.