Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2020
ReviewGenomics testing and personalized medicine in the preoperative setting: Can it change outcomes in postoperative pain management?
Postoperative pain and opioid use are major challenges in perioperative medicine. Pain perception and its response to opioid use are multi-faceted and include pharmacological, psychological, and genetic components. Precision medicine is a unique approach to individualized health care in which decisions in management are based on genetics, lifestyle, and environment of each person. ⋯ Although there is currently not enough evidence for making recommendations about genetic testing to guide pain management in the acute care setting, there are some known polymorphisms that play a role in surgical pain and opioid-related postoperative adverse outcomes. In this review, we describe the potential use of pharmacogenomics (PGx) for improving perioperative pain management. We first review a number of genotypes that have shown correlations with pain and opioid use and then describe the importance of PGx-guided analgesic protocols and implementation of screening in a preoperative evaluation clinical setting.
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Best Pract Res Clin Anaesthesiol · Jun 2020
ReviewPoint-of-care ultrasound in the preoperative setting.
Point-of-care ultrasound (POCUS) is a widely used diagnostic tool, especially in emergency and critical care medicine, and it is increasingly being used in the perioperative setting. Its specific role in preoperative assessment of patients, however, has not yet been defined. While some data show innovative use of the technique in the preoperative setting, higher-level evidence to underscore potential advantages is still limited. We review and discuss a range of POCUS examinations which can potentially help anaesthesiologists in the preoperative clinic decide whether to perform additional testing, can assist in selecting the best anaesthetic approach, and can support perioperative and postoperative monitoring.
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Best Pract Res Clin Anaesthesiol · Jun 2020
ReviewCognitive impairment assessment and interventions to optimize surgical patient outcomes.
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. ⋯ Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
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Best Pract Res Clin Anaesthesiol · Jun 2020
ReviewManaging preoperative anemia: Evolving concepts and strategies for improving patient outcomes.
Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. ⋯ Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.
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Best Pract Res Clin Anaesthesiol · Jun 2020
ReviewShared decision-making - Creating pathways and models of care.
Shared decision-making (SDM) is an essential element providing patient-centered perioperative care. Newer value-based healthcare models, defined as patient-centered outcomes versus the cost required to achieve these outcomes, will necessitate the use of metrics that reflect the alignment of treatment decisions with patient preferences and goals. ⋯ By learning methodologies to successfully incorporate SDM into clinical practice, anesthesiologists can increase the value of care they provide to their patients. The ideal means of achieving SDM within the complexity of modern medicine is not yet certain.