Anesthesia and analgesia
-
Perioperative interventions aimed at decreasing costs and improving outcomes have become increasingly popular in recent years. Anesthesiologists are often faced with a choice among different treatment strategies with little data available on the comparative cost-effectiveness. We performed a systematic review of the English language literature between 1980 and 2014 to identify cost-effectiveness analyses of anesthesiology and perioperative medicine interventions. ⋯ Overall, there remains a paucity of cost-effectiveness literature in anesthesiology, particularly relating to intraoperative interventions and multidisciplinary perioperative interventions. Based on the available studies, multidisciplinary perioperative optimization interventions such as accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles tended to be most cost-effective. Our review demonstrates that there is a need for more rigorous cost-effective analyses in many areas of anesthesiology and that anesthesiologists should continue to lead collaborative, multidisciplinary efforts in perioperative medicine.
-
Anesthesia and analgesia · Nov 2018
ReviewPerioperative Patient Blood Management to Improve Outcomes.
Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. ⋯ Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders.
-
Balanced general anesthesia, the most common management strategy used in anesthesia care, entails the administration of different drugs together to create the anesthetic state. Anesthesiologists developed this approach to avoid sole reliance on ether for general anesthesia maintenance. Balanced general anesthesia uses less of each drug than if the drug were administered alone, thereby increasing the likelihood of its desired effects and reducing the likelihood of its side effects. ⋯ Because these agents also decrease arousal, the doses of hypnotics and/or inhaled ethers needed to control unconsciousness are reduced. Effective use of this strategy requires simultaneous monitoring of antinociception and level of unconsciousness. We illustrate the application of this strategy by summarizing anesthetic management for 4 representative surgeries.
-
Anesthesia and analgesia · Nov 2018
Meta AnalysisDoes Respiratory Variation in Inferior Vena Cava Diameter Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-analysis.
We performed a systematic review and meta-analysis of studies investigating the diagnostic accuracy of respiratory variation in inferior vena cava diameter (ΔIVC) for predicting fluid responsiveness in patients receiving mechanical ventilation. ⋯ ΔIVC shows limited ability for predicting fluid responsiveness in distinct ventilator settings. In patients with TV ≥8 mL/kg and PEEP ≤5 cm H2O, ΔIVC was an accurate predictor of fluid responsiveness, while in patients with TV <8 mL/kg or PEEP >5 cm H2O, ΔIVC was a poor predictor. Thus, intensivists must be cautious when using ΔIVC.
-
Acute kidney injury (AKI) in the perioperative period is a common complication and is associated with increased morbidity and mortality. A standard definition and staging system for AKI has been developed, incorporating a reduction of the urine output and/or an increase of serum creatinine. Novel biomarkers may detect kidney damage in the absence of a change in function and can also predict the development of AKI. ⋯ Two recently published studies found that implementing this bundle in high-risk patients reduced the occurrence of AKI in the perioperative period. In addition, the application of remote ischemic preconditioning has been studied to potentially reduce the incidence of perioperative AKI. This review discusses the epidemiology and pathophysiology of surgery-associated AKI, highlights the importance of intraoperative oliguria, and emphasizes potential preventive strategies.