Anesthesia and analgesia
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Anesthesia and analgesia · May 2019
Meta AnalysisImpact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis.
Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions. ⋯ Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.
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Anesthesia and analgesia · May 2019
Meta AnalysisAwake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Why is this important?
This is the first systematic review of RCTs assessing different techniques for conducting awake fibreoptic intubation (AFOI), although the quality of evidence continues to be moderate-low.
Cabrini et al. reviewed 37 RCTs capturing 2,045 AFOI events.
What did they find?
There was no significant success difference among techniques for either local anaesthesia application or procedural sedation, including infusions or boluses of dexmedetomidine, propofol, opioids (fentanyl, sufentanil, remifentanil), ±midazolam, or sevoflurane.
Dexmedetomidine sedation resulted in the fewest desaturation events, and sevoflurane the fewest apnoea events.
Opioids used on their own (ie. without benzodiazepines) resulted in the highest patient recall, particularly remifentanil.
Also of interest...
When conducted by trained experts, AFOI is safe and effective regardless of technique and only very uncommonly results in intubation failure (0.59%) or severe adverse events (0.34%). No permanent morbidity or death was identified.
The take-home message:
When choosing a technique for awake fibre optic intubation, do what you do best – generally this will be what you and your institution are most experienced with.
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Anesthesia and analgesia · May 2019
ReviewNarrative Review of Decision-Making Processes in Critical Care.
Several theories describing the decision-making process in the intensive care unit (ICU) have been formulated. However, none of them appreciate the complexities of the process in an eclectic way by unifying several miscellaneous variables in 1 comprehensive theory. The purpose of this review is to highlight the key intricacies associated with the decision-making process in the ICU, to describe the theoretical frameworks with a special emphasis on gaps of knowledge, and to offer some avenues for improvement. ⋯ Furthermore, it is unclear when the preferential application of reflexive, habitual, variable, and biased-prone processes results in patient and staff detriment. We suggest better matching of theoretical frameworks with strengths of the human decision-making process and balanced application computer aids, artificial intelligence, and organizational modifications. The key component of this integration is work to increase the self-awareness of decision-making processes among residents, fellows, and attending physicians.
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Anesthesia and analgesia · May 2019
ReviewEvidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Colorectal Surgery.
The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery (ISCR), which is a national effort to disseminate best practices in perioperative care to more than 750 hospitals across multiple procedures in the next 5 years. The program will integrate evidence-based processes central to enhanced recovery and prevention of surgical site infection, venous thromboembolic events, catheter-associated urinary tract infections with socioadaptive interventions to improve surgical outcomes, patient experience, and perioperative safety culture. The objectives of this review are to evaluate the evidence supporting anesthesiology components of colorectal (CR) pathways and to develop an evidence-based CR protocol for implementation. ⋯ These guidelines/recommendations were supplemented by evidence made further literature searches. Anesthesiology protocol components were identified spanning the immediate preoperative, intraoperative, and postoperative phases of care. Components included carbohydrate loading, reduced fasting, multimodal preanesthesia medication, antibiotic prophylaxis, blood transfusion, intraoperative fluid management/goal-directed fluid therapy, normothermia, a standardized intraoperative anesthesia pathway, and standard postoperative multimodal analgesic regimens.
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Medications used in anesthesiology contain both pharmacologically active compounds and additional additives that are usually regarded as being pharmacologically inactive. These additives, called excipients, serve diverse functions. ⋯ Anesthesiologists should have a clear understanding of their chemical properties and the potential for adverse reactions. This report catalogs the excipients found in drugs commonly used in anesthesiology, provides a brief description of their function, and documents examples from the literature regarding their adverse effects.