Anaesthesia
-
In this paper I explain why I think that most of the models that predict postoperative mortality should not be used when we're talking to patients about postoperative survival. Available models are isolated in time (from survival in the present) and space (from survival outside hospital). We know a lot about survival outside hospitals, with sufficient detail that we can discriminate between a man born in 1975 vs. 1976, or a woman aged 64 years vs. 65 years. ⋯ We are also intervening earlier in progressive diseases, knowing that people are living long enough to experience harm from their progression. There is an evolving conflict between operating on older people and operating on younger people. Who has most to gain from the operation and who has most to gain from peri-operative critical care? Do we prioritise on reducing death now, in patients with relatively short life expectancies, or do we invest in the long-term survival of patients with relatively low rates of dying now? This conundrum is not informed by current risk models, with their focus on one to three postoperative months: we need to know survival outside hospital to gauge the value of what we do in hospital.
-
This review on shared decision-making comes at a time when international healthcare policy, domestic law and patient expectation demand a bringing-together of the patient's values and preferences with the physician's expertise to determine the best bespoke care package for the individual. Despite robust guidance in terms of consent, the anaesthetic community have lagged behind in terms of embracing the patient-focused rather than doctor-focused aspects of shared decision-making. For many, confusion has arisen due to a conflation of informed consent, risk assessment, decision aids and shared decision-making. ⋯ As patients have already decided to proceed with therapy or investigation and may be more concerned about the surgery than the anaesthesia, it is often assumed they will accept whatever anaesthetic is offered and defer to the clinician's expertise - without discussion. Furthermore, shared decision-making does not stop at time of anaesthesia for the peri-operative physician. It continues until discharge and requires the anaesthetist to engage in shared decision-making for prescribing and deprescribing peri-operative medicines.
-
Although there is reasonable confidence that a single general anaesthetic before three years of age has no consequences for intelligence development, there is an association between multiple exposures and learning and behavioural difficulties, possibly including ADHD. Animal studies have demonstrated ADHD-like changes in juvenile rats exposed to general anaesthetics.
There is a plausible physiological explanation for how general anaesthesia may induce ADHD, involving disruption of the prefrontal cortex and basal ganglia via dopaminergic, glutaminergic and neutrophic factor mechanisms.
Nonetheless, evidence to date linking general anaesthetic exposure in young children and ADHD development is far from conclusive and – as with many areas of practice – requires further research.
summary