Best practice & research. Clinical anaesthesiology
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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.
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Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewPerioperative cardiopulmonary exercise testing in the elderly.
The elderly constitute an increasingly large segment of the population and of the patients requiring medical attention. Major surgery is associated with a substantial burden of postoperative morbidity and mortality. Advancing age is a particular risk factor for these outcomes. ⋯ There is a consistent association between CPET-derived variables and outcome following major surgery. Furthermore, CPET-derived variables have utility in perioperative risk prediction and identification of patients at high risk of adverse outcome following major surgery. This optimal predictor appears to differ between various surgery types and the incremental benefit of combining CPET with alternative methods of perioperative risk prediction remains poorly defined.
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Best Pract Res Clin Anaesthesiol · Sep 2011
ReviewRenal injury in the elderly: diagnosis, biomarkers and prevention.
Acute kidney injury (AKI) in the elderly patient is a common iatrogenic complication of major surgery that impacts morbidity, mortality and resource use. Several renal functional and structural changes have been described, including a substantially decreased nephron mass. ⋯ The limitations of serum creatinine are much more pronounced in the elderly, including its dependence on muscle mass and the presence of multiple drug use and co-morbidities. Although it is conceivable that earlier AKI diagnosis and application of classical preventive measurements, including postponement of surgery or preference of medical treatment, optimisation of haemodynamics, euvolaemia, aggressive avoidance of nephrotoxic antibiotics or analgesics may translate into better patient outcomes, much more data are needed in this specific cohort.
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The American Society of Anesthesiologists (ASA) Closed Claims database was started in 1985 to study anaesthesia injuries to improve patient safety, now containing 8954 claims with 5230 claims since 1990. Over the decades, claims for surgical anaesthesia decreased, while claims for acute and chronic pain management increased. In the 2000s, chronic pain management involved 18%, acute pain management 9% and obstetrical anaesthesia formed 8% of claims. ⋯ The most common complications were death (26%), nerve injury (22%) and permanent brain damage (9%). The most common damaging events due to anaesthesia in claims were regional-block-related (20%), respiratory (17%), cardiovascular (13%) and equipment-related events (10%). This review examines recent findings and clinical implications for injuries in management of the difficult airway, MAC, non-operating room locations, obstetric anaesthesia and chronic pain management.
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Following the overwhelming evidence of adverse events in hospital practice, the World Health Organization (WHO)'s World Alliance for Patient Safety has launched the 'Safe Surgery Saves Lives' campaign, which has developed a surgical safety checklist aimed to improve patient safety. The implementation of this checklist has met with mixed reactions in different institutions. Many countries have still not adopted its use. In this article, a brief review is presented regarding the role of the WHO checklist, barriers to its implementation and strategies for successful adoption.