Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewThe role of tranexamic acid in the management of postpartum haemorrhage.
In the last decades, tranexamic acid (TXA) has emerged as an essential tool in blood loss management in obstetrics. TXA prophylaxis for postpartum haemorrhage (PPH) has been studied in double-blind, placebo-controlled, randomized clinical trials (RCTs). Given the small observed preventive effect, the systematic use of TXA for vaginal and/or caesarean deliveries remains controversial. ⋯ The TRACES in vivo analysis of biomarkers of TXA's antifibrinolytic effect have suggested that a dose of at least 1 g is required for the treatment of PPH. The TRACES pharmacokinetic model suggests that because TXA can be lost in the haemorrhaged blood, a second dose should be administered if the PPH continues or if severe coagulopathy occurs. Future pharmacodynamic analyses will focus on the appropriateness of TXA dosing regimens with regard to the intensity of fibrinolysis in catastrophic obstetric events.
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Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewPoint-of-care coagulation testing for postpartum haemorrhage.
The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. ⋯ There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.
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Best Pract Res Clin Anaesthesiol · Aug 2022
ReviewOperational and strategic decision making in the perioperative setting: Meeting budgetary challenges and quality of care goals.
Efficient operating room (OR) management is a constant balancing act between optimal OR capacity, allocation of ORs to surgeons, assignment of staff, ordering of materials, and reliable scheduling, while according the highest priority to patient safety. We provide an overview of common concepts in OR management, specifically addressing the areas of strategic, tactical, and operational decision making (DM), and parameters to measure OR efficiency. For optimal OR productivity, a surgical suite needs to define its main stakeholders, identify and create strategies to meet their needs, and ensure staff and patient satisfaction. OR planning should be based on real-life data at every stage and should apply newly developed algorithms.
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Best Pract Res Clin Anaesthesiol · Aug 2022
ReviewPerioperative leadership in the non-operating room and ambulatory setting.
To create a successful ambulatory care center, healthcare systems need management that can understand and improve key ambulatory success factors such as quality of clinical care, clinical competence, regulatory compliance, financial management, and customer service. Effective leadership is a vital skill that can improve all these factors. This manuscript discusses successful perioperative leadership styles in the ambulatory setting and provides a framework for proven strategies that have improved patient care.
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Leadership is an infinite and tremendously complex journey along with paradoxes that cannot be captured comprehensively. Over the past decades, key dimensions of leadership have caught the attention of practitioners in the field of management sciences. Yet, leadership education in healthcare is still limited. This personal perspective aims to summarize key aspects of leadership, ranging from managing people to managing systems and oneself.