Anesthesiology clinics
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Anesthesiology clinics · Mar 2015
ReviewMonitoring needs and goal-directed fluid therapy within an enhanced recovery program.
Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid requirements for abdominal surgery can be made but individualization of fluid prescription requires consideration of clinical signs and hemodynamic variables. ⋯ Application of this evidence to justify stroke volume optimization in the setting of major surgery within an enhanced recovery program is controversial. This article places the evidence in context, reviews controversies, and suggests implications for current practice and future research.
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Anesthesiology clinics · Mar 2015
ReviewPathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes.
Enhanced recovery pathways have been increasingly adopted into surgical specialties with the aim of reducing the stress response and improving the metabolic response to surgical insult. Enhanced recovery pathways encompass a large range of perioperative elements that together aim to restore a patient's gut function, mobility, function and well-being to preoperative levels as soon as feasible after major surgery. ⋯ This may not just have a benefit by reducing morbidity and mortality but also have an effect on long-term survival. There also may be additional benefits for patients with cancer.
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Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.
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Anesthesiology clinics · Dec 2014
ReviewWhich outcomes related to regional anesthesia are most important for orthopedic surgery patients?
An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.
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Anesthesiology clinics · Dec 2014
ReviewPerioperative management of the opioid tolerant patient for orthopedic surgery.
The prevalence of opioid use in the North America and some countries of the European Union has resulted in an increase in the number of patients who may exhibit opioid tolerance when requiring postoperative pain management. The approach to postoperative pain control in these patients is different from the strategies used in opioid-naïve patients. Better understanding of the cellular mechanisms of opioid tolerance in animals has resulted in the transfer of these concepts from the basic research to the clinical arena. This article presents new developments in opioid tolerance and how this knowledge can be applied to clinical practice.