Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Aug 2024
ReviewPlace of high-flow nasal oxygen in nonoperating room anesthesia.
This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings. ⋯ HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.
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Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. ⋯ To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.
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The environmental impact of anesthesia far exceeds that of other medical specialties due to our use of inhaled anesthetic agents (which are potent greenhouse gases) and many intravenous medications. ⋯ The environmental impact of anesthesia care should factor into our clinical decisions. The onus is on clinicians to safely care for our patients in ways that contribute the least harm to the environment. Intravenous anesthesia and regional techniques have less environmental impact than the use of inhaled agents; efforts to reduce and properly dispose of pharmaceutical waste are central to reducing environmental burden; desflurane should not be used; nitrous oxide should be avoided except where clinically necessary; central nitrous pipelines should be abandoned; low fresh gas flows should be utilized whenever inhaled agents are used.
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Curr Opin Anaesthesiol · Aug 2024
ReviewThe drug titration paradox: a control engineering perspective.
The drug titration paradox describes that, from a population standpoint, drug doses appear to have a negative correlation with its clinical effect. This paradox is a relatively modern discovery in anesthetic pharmacology derived from large clinical data sets. This review will interpret the paradox using a control engineering perspective. ⋯ This drug titration paradox describes the constraints of how the average clinician will dose a patient with an unknown clinical response. While our understanding of the paradox is still in its infancy, it remains unclear how alternative dosing schemes, such as through automation, may exceed the boundaries of the paradox and potentially affect its conclusions.