Best practice & research. Clinical anaesthesiology
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Incident reporting can be a powerful tool to detect weaknesses in the complex system of anaesthesiology. Having its roots in aviation, incident reporting today is used in a variety of medical disciplines at the local and even on the national level. Strength of incident reporting is the potential for learning from rare and potentially dangerous events. ⋯ It, furthermore, needs a sound definition or a model of a critical incident as well as a strategy to analyse the reported events. In Europe, a number of countries already run a national reporting system in anaesthesiology with large collections of critical events. These national systems, furthermore, distribute hazard warnings to spread the information on critical incidents among all specialists in that country.
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Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. ⋯ Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.
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Nearly 20% of all patients admitted to an intensive-care unit are obese. Their excess weight puts them at risk for several problems and complications during their intensive-care unit stay. Especially, pulmonary problems need particular attention, and comprehensive knowledge of the specific pathophysiologic changes of the respiratory system is important. ⋯ Careful positioning of the obese is essential to optimise ventilation and facilitate weaning from mechanical ventilation. Optimal hypocaloric nutrition with a high proportion of proteins is advised to control hyperglycaemia. Because mortality in obese patients is similar to or lower than in non-obese ones, it is conceivable that obesity has a protective effect in the critically ill.
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The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese--specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. ⋯ Surgery is not limited to the procedure itself, it also necessitates thorough preoperative evaluation, risk assessment, and counseling. The most common metabolic surgical procedures include Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion. Surgical outcomes for metabolic surgery are well studied and demonstrate superior long-term weight loss compared to medical management in cases of severe obesity.