Current opinion in anaesthesiology
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The increasing request for procedural sedation will create in the upcoming future the need for a specific training in delivering care to patients in a continuum of sedation, whose effects and adverse events are unpredictable. The main debate in the past years has been focused on using drugs that could have few adverse effects and could be considered well tolerated when administered by a nonanaesthesiologist. Propofol remains the most used drug for procedural sedation, but given its side-effects, its administration is limited and suggested only when an anaesthesiologist is available. The main studies recently appearing in the literature are focusing on the use of alternative drugs such as dexmedetomidine, remifentanil, fospropofol, ketofol and remimazolam. The current study is an overview of the different fields of procedural sedation, describing the evidence from the published studies and some upcoming studies. ⋯ Recent studies on procedural sedation are still debating on the use of propofol by nonanaesthesiologists and are exploring the use of other sedatives and analgesics. The main goal in the future should be to have a clear curriculum on the role of the 'sedationalist' outside the operating room.
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More surgical procedures are performed on an ambulatory basis and the advantages are apparent, but outpatient surgery presents challenges because of the expectation of a fast recovery soon after termination of anaesthesia. Ambulatory surgery is a well tolerated regimen with few serious adverse outcomes, hence difficult to obtain sound scientific evidence for avoiding complications. ⋯ The elderly are especially susceptible to adverse effects of the hospital environment such as immobilisation, sleep deprivation, unfamiliar surroundings, and medication errors. Enhanced recovery programmes (fast-track regimens) may allow earlier discharge which is probably beneficial for the elderly. Frailty is becoming an increasingly important concept that needs to be clinically considered in elderly patients, as well as in future studies.
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Electronic medical devices are an integral part of patient care. As new devices are introduced, the number of alarms to which a healthcare professional may be exposed may be as high as 1000 alarms per shift. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in five years. The Joint Commission, recognizing the clinical significance of alarm fatigue, has made clinical alarm management a National Patient Safety Goal. ⋯ Alarm fatigue can jeopardize safety, but some clinical solutions such as setting appropriate thresholds and avoiding overmonitoring are available.
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There is an increasing interest in the application of near-infrared spectroscopy (NIRS) as a monitoring tool in noncardiac surgery. This review summarizes the latest developments and current evidence for the use of NIRS in the noncardiac intraoperative setting. ⋯ NIRS offers noninvasive monitoring of cerebral and overall organ oxygenation in a wide range of clinical scenarios. There is an increasing evidence that the optimized cerebral oxygenation is associated with improved outcomes in both neurologic and major organ morbidity in a variety of surgical settings.