Anaesthesia
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It is widely recommended that beta-blockade be used peri-operatively as it may reduce the incidence of postoperative cardiovascular complications including death. However, there are few data concerning the cost-effectiveness of such strategies. We have analysed the pharmacoeconomics of acute beta-blockade using data from eight prospective peri-operative studies in which patients underwent elective non-cardiac surgery, and in which the incidence of adverse side-effects of treatment, as well as clinical outcomes, have been reported. ⋯ The incremental cost of peri-operative beta-blockade (costs of drug acquisition and of treating associated adverse drug events) was 67.80 pounds sterling per patient. This results in a total cost of 1254.30 pounds sterling per peri-operative cardiovascular complication prevented. However, there is evidence that in patients at lower cardiovascular risk, beta-blockers may be potentially harmful, since their adverse effects (hypotension, bradycardia) may outweigh their potential cardioprotective effects.
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The prevalence of obesity continues to increase despite preventive strategies. Obese parturients are at increased risk of having either concurrent medical problems or superimposed antenatal diseases such as pre-eclampsia and gestational diabetes. Moreover, they have a tendency to labour abnormally contributing to increased instrumental delivery and Caesarean section. ⋯ The mother's life should not be jeopardised to save a compromised fetus. Prophylactic placement of an epidural catheter when not contraindicated in labouring morbidly obese women would potentially decrease anaesthetic and perinatal complications associated with attempts at emergency provision of regional or general anaesthesia. Early mobilisation, aggressive chest physiotherapy and adequate pain control are essential components of effective postoperative care.
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Controlled Clinical Trial
Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events.
We examined whether a combined critical care outreach and acute pain service comprising both medical and nursing staff from the Department of Anaesthesia would decrease the incidence of postoperative serious adverse events in a hospital with an established Medical Emergency Team. We called this combined service ⋯ Inpatient Management of acute Pain and Advice on Clinical Treatment. We conducted a prospective, before-and-after trial with a baseline phase (319 patients) of standard acute pain management followed by the IMPACT phase (271 patients), during which the IMPACT team systematically reviewed high-risk postoperative patients for the first three days after their return to the general wards. The incidence of serious adverse events decreased from 23 events per 100 patients to 16 events per 100 patients. The 30-day mortality decreased from 9% to 3%, p = 0.004. An acute pain service providing critical care outreach may improve postoperative outcome but the workload is considerable.