Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2017
ReviewWorking toward quality in obstetric anesthesia: a business approach.
Physicians are increasingly required to demonstrate that they provide quality care. How does one define quality? A significant body of literature in industries outside of health care provides guidance on how to define appropriate metrics, create teams to troubleshoot problem areas, and sustain those improvements. ⋯ The review will discuss the process for creating an effective quality program for an obstetric anesthesia division. Sustainable improvements in delivered care need to be based on an evaluation of service line needs, defining appropriate metrics, understanding current process flows, changing and measuring those processes, and developing mechanisms to ensure the new processes are maintained.
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As clinicians preparing patients for general anesthesia, should we consider the possibility of concussion in our elective operative patients? If so, why is this necessary? Is it possible that exposure to an anesthetic is detrimental to recovery from concussion? If so, what should we do about the imperative/urgency for surgery? No answers are promised in this review. Rather, the focus is on the questions and approaches taken in the recent literature, as well as highlighting a need for more research. ⋯ This review provides a perspective about autonomic nervous system function and cerebrovascular effects of concussion, and some relevant clinical issues that warrant further clinical study.
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This review will deliberate on contemporary concepts regarding the frailty syndrome and its association with the perioperative period. Frailty syndrome and its relevance to organ systems, scoring tools and intervention measures will be discussed in detail. ⋯ Preoperative frailty is associated with significant morbidity and mortality. Recently, frailty assessment tools have been developed and show good ability to predict postoperative adverse events. These tools might become a preoperative routine, as they set the ground for patient's selection, guide perioperative interventions for the frail elderly population and thus may influence patient's outcome.
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Curr Opin Anaesthesiol · Jun 2017
ReviewPrevention of respiratory complications of the surgical patient: actionable plan for continued process improvement.
Postoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common. ⋯ Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.