Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2009
ReviewPerioperative management of ambulatory surgical patients with diabetes mellitus.
Patients with diabetes frequently present for ambulatory surgery concomitant with the rise in incidence of the disease. This review will examine recent evidence on glucose control, the harmful effects of hyperglycemia, fluctuations of blood glucose, and hypoglycemia, as well as treatments and medications utilized for type 1 and type 2 diabetes mellitus. Based on this evidence, a strategy for perioperative decision making for the diabetic patient undergoing ambulatory surgery will be presented. ⋯ The ambulatory anesthesiologist, with a dedication to low-impact practices and emphasis on rapid recovery, provides an ideal environment of care for the patient with diabetes. This review will examine issues and concerns with management of the patient with diabetes undergoing ambulatory surgery and address them in a step-wise strategy for care, including recommendations for perioperative insulin administration.
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Curr Opin Anaesthesiol · Dec 2009
ReviewTotal intravenous anaesthesia techniques for ambulatory surgery.
The purpose of the present review is to provide an updated discussion on the use of total intravenous anaesthesia (TIVA) for ambulatory surgery, based on results from recent studies put into the context of issues already known. ⋯ TIVA is well tolerated and simple. It is associated with less postoperative nausea and vomiting than inhalational anaesthesia and has no residual paralyses as are possible with locoregional techniques. Propofol with remifentanil seems to be the dominating TIVA technique, delivered either by conventional pumps or by target control systems.
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Curr Opin Anaesthesiol · Dec 2009
ReviewPreoperative screening and risk assessment in the ambulatory surgery patient.
With the rapid increase in the number of sicker patients with multiple co-morbidities and extremes of age who are undergoing ambulatory surgery, a thorough and detailed preoperative workup has become increasingly important. Case cancellation on the morning of surgery should be an exception. Therefore, much attention is focused on the optimization of the sicker patients. Although the anesthesiologist plays a central role in the preoperative assessment, a multidisciplinary approach is critical. This review was done to provide the reader with current trends and practices in preoperative assessment of the ambulatory surgical patient. ⋯ Risk management involves the identification of the patient at risk, optimization of preoperative health status, risk reduction through medical intervention as well as appropriate perioperative care. Thus, patient outcome can be improved, specifically for the sicker patients at a higher risk.
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The focus of intraoperative monitoring is moving away from invasive monitoring. This has been attributed to procedure time, cost, and the known risks, which include carotid artery puncture, arrhythmia, pneumothorax, and infection. Until recently, the venous system's contribution to the circulatory system has been incorrectly identified as being insignificant. This article summarizes the unique characteristics of the peripheral venous system. ⋯ The veins play a critical role in cardiovascular homeostasis; they do more than conduct blood to the heart. Considering the ease of measurement from a peripheral intravenous catheter, further study should be conducted to investigate the usefulness and limitations of such a minimally invasive and inexpensive monitoring device.
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We outline and discuss recent work on auditory displays, covering both auditory alarms that indicate technical or physiological threshold levels and informative auditory displays that provide a continuous awareness of a patient's well being. ⋯ Auditory display in anesthesia can extend well beyond auditory alarms to displays that give the anesthesiologist a continuous peripheral awareness of patient well being. Much more rigorous approaches should be taken to evaluating auditory displays so they add information rather than noise.