Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2018
ReviewPostanesthesia care by remote monitoring of vital signs in surgical wards.
Boer, Touw and Loer describe the concept of continuous, remote vital sign monitoring and the current level of evidence for it's proposed benefit.
We know that...
- Post-operative complications occur in 25-40% of patients, making this the most important focus for improving perioperative outcomes.
- Failure to rescue is a common problem, and few postoperative patients actually experience sudden deterioration, instead hindsight shows a slow and steady decline leading to the critical event that generates an emergency response.
Continuous remote vital sign monitoring on surgical wards may improve early recognition of deterioration.
- Remote monitoring uses medical-grade biosensors wirelessly linked to a central receiver, integrated with an electronic patient record, allowing patients free movement.
- The handful of currently available systems monitor combinations of heart rate ± variability, ECG, respiratory rate, pulse oximetry, blood pressure, temperature, posture and activity.
- Continuous monitoring may then be integrated with systems that calculate an Early Warning Score, automatically notify staff of early deterioration, or in more advanced future systems, allow prediction of deterioration.
- Although feasible, all current systems suffer from practical and technical issues that can limit their sensitivity and specificity.
So, any real evidence?
- Evidence of benefit is still very patchy, although data suggests that automated notification of deterioration leads to earlier responses by treating teams, with small interventions, reducing the burden on rapid response / MET systems.
- No actual morbidity or mortality outcome data is yet available.
Be cautious...
While the hope is that remote monitoring can improve patient safety, it could disingenuously be used to justify reduced ward staffing and hospital stay length by normalizing the risk of our current postoperative harm status quo.
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Curr Opin Anaesthesiol · Dec 2018
ReviewNeuromonitoring in the ambulatory anesthesia setting: a pro-con discussion.
Various neurologically focused monitoring modalities such as processed electroencephalography (pEEG), tissue/brain oxygenation monitors (SbO2), and even somatosensory evoked responses have been suggested as having the potential to improve the well tolerated and effective delivery of care in the setting of outpatient surgery. The present article will discuss the pros and cons of such monitors in this environment. ⋯ The use of advanced neuromonitoring techniques (primarily pEEG) may be considered reasonable in two instances: for the prevention of intraoperative awareness during the administration of total intravenous anesthesia coupled with the use of a neuromuscular blocking drug, and for the prevention of relative drug overdose (and possibly postoperative delirium) in the elderly.
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Curr Opin Anaesthesiol · Dec 2018
ReviewEcho-guided invasive pain therapy: indications and limitations.
The purposes of this review are to summarize the advantages and limitations of ultrasound-guided pain interventions, and to illustrate those interventions with peripheral, axial and musculoskeletal pain procedures. ⋯ Pain intervention under ultrasound guidance is particularly valuable in peripheral and musculoskeletal procedures. There is growing interest of its application in cervical spine and sacroiliac joint. More outcome studies are required in the future to make ultrasound-guided pain intervention as the established procedure.
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Curr Opin Anaesthesiol · Dec 2018
ReviewRebound pain after regional anesthesia in the ambulatory patient.
Regional anesthesia is popular in ambulatory setting allowing safe and fast recovery. The problem of 'rebound pain', that is very severe pain when peripheral nerve block (PNB) wears off represents a clinically relevant problem and a cause of increased healthcare resource utilization. This review tries to make the point on a not so rare, unwanted and often neglected side effect of PNB. ⋯ Patients' report of excruciating pain and major distress when PNB wears off questions the quality of current anesthesia practice in ambulatory setting. Rebound pain unanswered questions are challenging in the area of perioperative medicine.
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The increasing number of procedures done in the ambulatory surgical setting necessitates the need for analgesic modalities that enable the management of postsurgical pain with fast onset, predictable duration of action, and minimal need for management of undesirable side-effects. ⋯ Local anesthetics, opioids, and NSAIDS are the mainstay of multimodal analgesic management, and as such, improving their efficacy in the ambulatory surgical setting remains the primary focus. However, as knowledge of the modulating pathways involved in transduction of pain increases, newer agents that utilize this knowledge are also becoming more widely available.