Anaesthesia
-
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 -
Although the concept of pre-operative optimisation is traditionally applied to elective surgery, there is ample opportunity to apply similar principles to patients undergoing emergency laparotomy. The key challenge is achieving meaningful improvements in a patient's condition without introducing delays to time-sensitive surgery, which may be required in a matter of hours. ⋯ Optimising the patient's condition is less about improving long-term pathology, and more about correcting physiological derangement, such as electrolyte and fluid balance, blood loss, prompt treatment of sepsis, and ensuring appropriate continuation of medication in the peri-operative period. Optimising the care pathway involves ensuring that the system is designed to deliver reliably the appropriate interventions, such as prompt antibiotics, and access to computed tomography scanning and the operating theatre with minimal delay.
-
Anaemia in surgical patients is a common and serious problem; around 40% of patients presenting for major surgery are anaemic. Patients with pre-operative anaemia have significantly higher rates of morbidity and mortality and are likely to be transfused red cells. In addition, red cell transfusions are independently associated with worse outcomes. ⋯ The most common cause of pre-operative anaemia is iron deficiency, which can be treated with iron therapy. Iron clinics should be set up in either primary or secondary care to allow for optimal treatment. In this review, we present literature supporting the optimisation of pre-operative anaemia and propose a treatment algorithm.
-
Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. ⋯ Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.