Current opinion in anaesthesiology
-
Curr Opin Anaesthesiol · Aug 2014
ReviewScheduling for anesthesia at geographic locations remote from the operating room.
Providing general anesthesia at locations away from the operating room, called remote locations, poses many medical and scheduling challenges. This review discusses how to schedule procedures at remote locations to maximize anesthesia productivity (see Video, Supplemental Digital Content 1). ⋯ Remote locations with sufficient hours of cases should be allocated time reserved especially for them in which to schedule their cases, with a maximum waiting time of 2 weeks, to achieve an average wait of 1 week.
-
Curr Opin Anaesthesiol · Aug 2014
ReviewManagement of right ventricular dysfunction in the perioperative setting.
This review summarizes the approach to and recent developments in the treatment of acute right ventricular dysfunction and failure in the perioperative setting. Right ventricular failure, defined as the inability to deliver sufficient blood flow through the pulmonary circulation at normal central venous pressure, is a common problem in the perioperative setting and is associated with an increased mortality. The failure of the right ventricle is caused by reduced right ventricular contractility or an increased right ventricular afterload or both. ⋯ Right ventricular dysfunction may cause venous congestion and systemic hypoperfusion. After identifying right ventricular dysfunction, the primary goal is to correct reversible causes of excessive load or reduced right-ventricular contractility. If the underlying abnormalities cannot be reversed, diuretic, vasodilator, or inotropic therapy may be required.
-
Curr Opin Anaesthesiol · Aug 2014
ReviewManagement of anaesthetic emergencies and complications outside the operating room.
Anesthesia outside the operating room is commonly uncomfortable and risky. In this setting, anesthetic emergencies or complications may occur. This review aims to report the most recent updates regarding the management of prehospital anesthesia, anesthesia in the trauma and emergency rooms, and anesthesia for endoscopy and interventional radiology. ⋯ Anesthesia outside the operating room requires careful monitoring to avoid side-effects and education of nonanaesthetists when they are involved. A useful tool is to continuously improve the protocols and checklists to make anesthesia in this setting safer.
-
Curr Opin Anaesthesiol · Aug 2014
Review'New' direct oral anticoagulants in the perioperative setting.
Out of the anesthetist's perspective, some uncertainties remain with the perioperative management of the so-called NOACs. This review emphasizes on the question of bleeding and thromboembolic risk as well as the management of bleedings and the discontinuing intervals in the context of regional anesthesia. ⋯ NOACs like dabigatran etexilate, rivaroxaban, apixaban and edoxaban are effective alternatives to warfarin in primary and secondary prophylaxis of thromboembolic conditions. In the perioperative setting, some uncertainties and evidence gaps remain in estimating the bleeding risks associated with surgical procedures, emergency trauma and neuroaxial anesthesia. A discontinuation of NOACs should be at least 1 day before elective operation. Renal and liver impairment, older age, or co-medications could afford longer intervals. As no specific reversal agents are yet available for life-threatening bleeding or emergency surgery; nonspecific prohemostatic therapies are mainly recommended. Oral charcoal, application of tranexamic acid or hemodialysis could bring additional benefit depending on the individual NOAC. Practitioners need to be aware that NOACs can interfere in different pathways with the measurement of common hemostasis parameters. Estimating the bleeding risks and reversal strategies requires careful evaluation also in the light of a potential risk of thromboembolic complications. In difference to warfarin, 'bridging' concepts are not generally recommended for NOACs.