Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2005
ReviewDoes perioperative pulse oximetry improve outcome? Seeking the best available evidence to answer the clinical question.
The aim of this chapter is to clarify the effect of perioperative monitoring with pulse oximetry and to identify the adverse outcomes that might be prevented or improved by its use. Trials were identified by computerized searches of The Cochrane Library, MEDLINE and EMBASE, and by checking the reference lists of trials and review articles. All controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period, including the operating and recovery room, were included in the search. ⋯ The implementation of perioperative pulse oximetry monitoring does not significantly reduce the number of postoperative complications, but the question remains whether pulse oximetry can improve outcomes in other situations. Pulse oximetry has been adopted all over the world in clinical practice as a tool that guides anaesthesiologists in the daily management of patients: in teaching situations, in emergencies, and especially in the care of children. Given the relatively small number of patients studied in these trials and the rare events being sought, the studies of perioperative monitoring with pulse oximetry were not able to show an improvement in the outcomes studied.
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During the last 20 years, studies using continuous perioperative electrocardiogram (ECG) monitoring in patients at high risk for postoperative cardiac complications have revolutionized our understanding of the pathophysiology, circumstances, timing and possible prevention of perioperative ischemia and postoperative cardiac morbidity and mortality. The present review attempts to provide a comprehensive and practical summary of the current knowledge on perioperative myocardial ischemia. It starts with a description of the conventional definition of myocardial ischemia on exercise stress-testing and continues with a summary of the findings and insights collected from ambulatory Holter monitoring in non-surgical patients with coronary artery disease. It then recaps the variety of studies using perioperative ischemia monitoring to detail the concepts and controversies brought about by this type of monitoring, and tries to portray a general picture of the association of perioperative ischemia and postoperative cardiac complications-including myocardial infarction-and emphasize the importance of postoperative, not just intraoperative, ischemia monitoring.
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Despite considerable investment of resources, there remains wide variation in organization of Intensive Care Units (ICUs). One key domain is the physician staffing. ⋯ The improved sense of continuity and close attendance to patients may also bolster improved patient and family satisfaction. Intensivist-led or intensivist-staffed ICUs may also realize decreased resource use because these physicians may be better at reducing inappropriate admissions, preventing complications that prolong length of stay, and recognizing opportunities for prompt discharge.
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Best Pract Res Clin Anaesthesiol · Mar 2005
ReviewPerioperative management of the chronic pain patient.
The chronic pain patient has certain distinctive features important for her/his perioperative management. Altered opioid sensitivity and behavior are the major points to be considered. ⋯ Although a number of characteristics-including increased opioid demand, underreporting of pain, and non-compliance--are known, only a few specific recommendations are available, viz. adequate increase of opioid dose for analgesia, continuation of pre-operative opioids and coanalgesics to prevent withdrawal, and intensive education to strengthen the patient's coping potential. No differences between specific techniques for post-operative analgesia (e.g. systemic, patient-controlled or regional analgesia) have been shown so far.
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Best Pract Res Clin Anaesthesiol · Mar 2005
ReviewThe pediatric patient and upper respiratory infections.
Children frequently present for elective surgery in the setting of an active or recent upper respiratory infection. Respiratory adverse events are increased in this setting, but the threshold for cancelling a case varies widely between clinicians. ⋯ More data are needed on the risks of proceeding with surgery in the presence of these factors and on the impact of potential therapies to decrease the incidence of adverse events. Lidocaine and other therapies that reduce laryngospasm in well patients need to be evaluated in children with upper respiratory infection.