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.
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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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Best Pract Res Clin Anaesthesiol · Jun 2011
ReviewNon-technical skills for anaesthetists: developing and applying ANTS.
This article examines the non-technical skills approach to enhancing operational safety, with particular reference to anaesthesia. Training and assessing the non-technical skills of staff in safety-critical occupations is accepted by high-risk industries, most notably aviation, but has only recently been adopted in health care. ⋯ This was the first non-technical skills framework specifically designed for anaesthetists, and the authors explain how ANTS was designed as well as its use for selection, training and assessment. Finally, the article mentions similar tools available for surgeons (NOTSS) and scrub nurses (SPLINTS), as well as research activities to develop behavioural rating systems for obstetric anaesthetists and anaesthetic assistants.