Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2012
ReviewPreoperative optimization: rationale and process: is it economic sense?
The development of preoperative clinics and the increasing importance of the anaesthetist in the management of surgical risk have expanded the concept of preoperative optimization. This review will focus on the rationale and process for cost-effective preoperative optimization. ⋯ The requirement for appropriate methods of risk stratification of surgical patients targeted at the reduction of postoperative morbidity, underpins the development of cost-effective preoperative optimization. Specific process-based and clinical measures may then be applied to the development of individualized perioperative care packages.
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The current economic climate has put pressure on healthcare systems and providers, including anesthesiologists, to minimize costs without sacrificing patient safety. In this review, we discuss costs associated with anesthesia care, including medications and intraoperative monitoring, and suggest ways to reduce wastes and overall expenditure. ⋯ Anesthesia medications comprise a significant proportion of hospital pharmacy budgets. Average anesthesia-related cost reductions of US$ 13-30 per cases multiplied by 25 million anesthetics administered annually in the USA has the potential to yield savings of US$ 350-750 million. Bispectral index monitoring during inhalational anesthesia adds to the cost without providing any benefit.
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Mechanical ventilation is essential for the support of critically ill patients, but may aggravate lung damage, leading to ventilator-associated lung injury (VALI). VALI results from a succession of events beginning with mechanical alteration of lung parenchyma, because of disproportionate stress and strain. The resulting structural tension initiates a biological inflammatory cascade; however, tension can reach the limits of stress, triggering the destruction of structures. This article reviews and discusses the ongoing research into the mechanisms of VALI and their implications for the management of ventilated patients. ⋯ How ventilation strategy, specific mechanisms of mechanotransduction, and their individual threshold values impact on VALI remains to be elucidated. In addition, clinical studies are required to evaluate the usefulness of individualized ventilator strategies based on lung mechanics.
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Curr Opin Anaesthesiol · Apr 2012
ReviewSpontaneous breathing activity in acute lung injury and acute respiratory distress syndrome.
We aimed at providing the most recent and relevant evidence regarding spontaneous breathing activity during mechanical ventilation in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Both clinical and experimental data are depicted. ⋯ In our opinion, spontaneous breathing activity should be avoided in the first 48 h of mechanical ventilation in patients with severe ARDS (PaO2/FIO2 <120 mmHg), but it may be useful in less severe ARDS and ALI. Clearly, further clinical and experimental investigations on the use of different ventilation modes of supported/unsupported spontaneous breathing in ALI/ARDS are needed.