Best practice & research. Clinical anaesthesiology
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The aim of this chapter is to focus on evidence-based health economics in anaesthesia. More and more, requests for additional facilities will have to be based on detailed arguments supported by 'hard evidence' as to the gain to be expected from the patient's angle and the cost. ⋯ This chapter shows how to bring economic evaluation and systematic review together, and how to use such evaluations in the clinical setting. It shows how economics can be used to broaden the evidence base for a more efficient and equitable health policy, and sets a future research agenda for this challenging area of work in Cochrane reviews dealing with anaesthesia topics.
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Perioperative fluid therapy is the subject of much controversy, and the results of the clinical trials investigating the effect of fluid therapy on outcome of surgery seem contradictory. The aim of this chapter is to review the evidence behind current standard fluid therapy, and to critically analyse the trials examining the effect of fluid therapy on outcome of surgery. The following conclusions are reached: current standard fluid therapy is not at all evidence-based; the evaporative loss from the abdominal cavity is highly overestimated; the non-anatomical third space loss is based on flawed methodology and most probably does not exist; the fluid volume accumulated in traumatized tissue is very small; and volume preloading of neuroaxial blockade is not effective and may cause postoperative fluid overload. ⋯ Without evidence of the existence of a non-anatomical third space loss and ineffectiveness of preloading of neuroaxial blockade, 'restricted intravenous fluid therapy' is not 'restricted', but rather avoids fluid overload by replacing only the fluid actually lost during surgery. The trials of different fluid volumes administered during outpatient surgery confirm that replacement of fluid lost improves outcome. Based on current evidence, the principles of 'restricted intravenous fluid therapy' are recommended: fluid lost should be replaced and fluid overload should be avoided.
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Best Pract Res Clin Anaesthesiol · Jun 2006
ReviewPostoperative cognitive dysfunction: incidence and prevention.
Postoperative cognitive dysfunction (POCD) is a decline in cognitive function for weeks or months after surgery. Due to its subtle nature, neuropsychological testing is necessary for its detection. ⋯ The risk of POCD increases with age, and the type of surgery is also important because there is a very low incidence associated with minor surgery. Regional anaesthesia does not seem to reduce the incidence of POCD, and cognitive function does not seem to improve after carotid surgery as has previously been suggested.
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Acupuncture and related techniques are increasingly practised in anaesthesia. This paper reviews the current evidence and applicability of acupuncture and related techniques for anaesthetic procedures and postoperative nausea and vomiting. Recent evidence suggests that manual acupuncture is effective for reducing preoperative anxiety and for postoperative pain relief. ⋯ The use of acupuncture for labour pain management appears promising but requires further research. Patient selection, acupoint selection, needling techniques, and mode of acupuncture need to be considered when applying acupuncture and related techniques in the perioperative setting. There are guidelines for the conduct and reporting of acupuncture research, and these should be followed to improve the quality of studies.