Anaesthesia
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Virtual reality is a computer-generated environment that immerses the user in an interactive artificial world. This ability to distract from reality has been utilised for the purposes of providing pain relief from noxious stimuli. As technology rapidly matures, there is potential for anaesthetists and pain physicians to incorporate virtual reality devices as non-pharmacological therapy in a multimodal pain management strategy. ⋯ Twelve studies showed reduced pain scores in acute or chronic pain with virtual reality therapy, five studies showed no superiority to control treatment arms and in one study, the virtual reality exposure group had a worsening of acute pain scores. Studies were heterogeneous in: methods; patient population; and type of virtual reality used. These limitations suggest the evidence-base in adult patients is currently immature and more rigorous studies are required to validate the use of virtual reality as a non-pharmacological adjunct in multimodal pain management.
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Chronic obstructive pulmonary disease is a condition commonly present in older people undergoing surgery and confers an increased risk of postoperative complications and mortality. Although predominantly a respiratory disease, it frequently has extra-pulmonary manifestations and typically occurs in the context of other long-term conditions. Patients experience a range of symptoms that affect their quality of life, functional ability and clinical outcomes. ⋯ Pharmacological treatment should also be optimised, and some patients may benefit from lung volume reduction surgery. Psychological and behavioural factors are important, but are currently poorly understood in the peri-operative period. Considerations of the risk and benefits of delaying surgery to ensure the recommended measures are delivered depends on patient characteristics and the nature and urgency of the planned intervention.
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Non-invasive haemoglobin measurement using absolute values lacks the precision to be the sole basis for the treatment of pre-operative anaemia. However, it can possibly serve as a screening test, indexing 'anaemia' with high sensitivity when values remain under prespecified cut-off values. Based on previous data, non-invasive haemoglobin cut-off values (146 g.l-1 for women and 152 g.l-1 for men) detect true anaemia with 99% sensitivity. ⋯ Patient and measurement characteristics did not influence the agreement between non-invasive and laboratory haemoglobin levels. Although sensitivity was very high, the index test using prespecified cut-off values just failed to reach the target sensitivity to detect true anaemia. Nevertheless, with respect to blood-sparing effects, the use of the index test in men may be clinically useful, while an index test with a lower cut-off (132 g.l-1 ) could be more clinically appropriate in women.
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Practice Guideline
PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations.
Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. ⋯ Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.