Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2008
ReviewMultimodal multidisciplinary standardization of perioperative care: still a long way to go.
The complexity of the perioperative care process has resulted in a suboptimal use of resources, quality problems and a relatively high incidence of errors. In an attempt to optimize resources, patient safety, and quality, multimodal, multidisciplinary standardization of the care process has become an increasingly recognized goal. ⋯ Although recent literature indicates that standardization of perioperative care improves efficiency, quality, and patient satisfaction, implementation of standardized care is difficult since resistance is still enormous.
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Curr Opin Anaesthesiol · Apr 2008
ReviewTherapeutic hypothermia after out-of hospital cardiac arrest: how to secure worldwide implementation.
Despite the scientific evidence, therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors is still not widely used. It is unlikely that technical, logistical and financial barriers alone can explain the geographically large differences in its application. Our review focuses on how generic knowledge on implementation may help speed up the transfer of therapeutic hypothermia into daily practice. ⋯ More than 40 years after the late Peter Safar first suggested therapeutic hypothermia as standard therapy during postresuscitation care, worldwide implementation of this treatment seems possible. To secure this, however, hospitals and health systems must institute well defined implementation plans taking local cultural and organizational barriers into account.
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The traditional approach to trauma patients with presumed internal hemorrhage has been immediate, aggressive intravenous fluid resuscitation. Recent experimental and clinical data, however, suggest a more discriminating approach that first considers concurrent head injury, hemodynamic stability and the presence of potentially uncontrollable hemorrhage (e.g. deep truncal injury) versus a controllable source (e.g. distal extremity wound) as well as the use of new techniques to inhibit bleeding and better ways to monitor the patient's condition. ⋯ Owing to the growing societal threat of trauma, further research, including studies already under way, will be critical to delineate the timing and technique of infusing advantageous resuscitative fluids such as hypertonic saline and hemoglobin-based oxygen carriers as well as the use of hemostatic agents and special blood products.
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This article reviews new findings on the use of vasopressor agents in septic shock. ⋯ The use of norepinephrine or epinephrine can be left to the discretion of the treating physician. Low-dose vasopressin administration remains an option for catecholamine-refractory septic shock. The potential benefit of early use in combination with a moderate dose of norepinephrine remains to be determined.
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Being critical in terms of time and complexity, emergency medicine is exposed to an emerging imperative for quality improvement strategies. We review current concepts and recent advances in the management of quality in emergency medicine. ⋯ According to the available evidence, more performance improvement strategies need to be tested to delineate which process changes would be most effective in improving patient outcome in emergency medicine.