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Korean Journal of Anesthesiology Feb 2020The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these... (Review)
Review
The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.
Topics: Age Factors; Aged; Anesthesiologists; Anesthesiology; Anesthetics; Humans; Perioperative Care; Postoperative Complications
PubMed: 31636241
DOI: 10.4097/kja.19391 -
Anaesthesia Jan 2018Adverse drug reactions are a cause of significant morbidity and mortality to patients and a source of financial burden to the healthcare system. Of the wide spectrum of... (Review)
Review
Adverse drug reactions are a cause of significant morbidity and mortality to patients and a source of financial burden to the healthcare system. Of the wide spectrum of adverse drug reactions, the most concerning to the anaesthetist remain anaphylaxis and malignant hyperthermia. Although the incidence of anaphylaxis under anaesthesia is difficult to ascertain, it occurs commonly enough that most anaesthetists will manage at least one case in their career. The wide range of drugs given in the peri-operative period and the variable presentation in the anaesthetised patient can delay diagnosis and treatment, and adversely affect outcome. Furthermore, despite improvements in testing, causative drugs can still be difficult to identify, as adverse reactions may be mediated by mechanisms other than IgE activation. With an increase in the reporting of anaphylaxis to newer anaesthetic drugs such as sugammadex, combined with change over the recent decades in the most likely causative peri-operative agents, it is imperative anaesthetists remain up to date on recent developments. In addition, they should be vigilant to patient characteristics, including pharmacogenetic variations that may predispose to adverse drug reactions, in order to help minimise risks of a reaction. The severity of adverse drug reactions to peri-operative drugs means morbidity and mortality remain high.
Topics: Anaphylaxis; Anesthesia; Anesthetics; Drug Hypersensitivity; Drug-Related Side Effects and Adverse Reactions; Humans; Incidence
PubMed: 29313907
DOI: 10.1111/anae.14143 -
British Journal of Anaesthesia Nov 2020The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere,... (Review)
Review
The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the 'state of the art' environmental sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. 'cradle to grave' analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.
Topics: Anesthesia; Anesthesiology; Anesthetics; Carbon; Climate Change; Conservation of Natural Resources; Critical Care; Environmental Pollutants; Environmental Pollution; Equipment Reuse; Humans; Recycling; Shock, Septic
PubMed: 32798068
DOI: 10.1016/j.bja.2020.06.055 -
Anesthesia Progress 2018Hypertension is an important health challenge that affects millions of people across the world today and is a major risk factor for cardiovascular disease. It is... (Review)
Review
Hypertension is an important health challenge that affects millions of people across the world today and is a major risk factor for cardiovascular disease. It is critical that anesthesia providers have a working knowledge of the systemic implications of hypertension. This review article will discuss the medical definitions of hypertension, the physiology of maintaining blood pressure, outpatient treatment of hypertension, anesthetic implications, and the common medications used by anesthesia providers in the treatment of hypertension. Part I provided an overview of hypertension and blood pressure regulation. In addition, drugs predominantly affecting control of hypertension via renal mechanisms such as diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and renin-inhibiting agents were discussed. In part II, the remaining major antihypertensive medications will be reviewed as well as anesthetic implications of managing patients with hypertension.
Topics: Anesthesia; Anesthetics; Antihypertensive Agents; Blood Pressure; Drug Interactions; Humans; Hypertension; Patient Safety; Risk Assessment; Risk Factors; Surgical Procedures, Operative
PubMed: 30235430
DOI: 10.2344/anpr-65-03-17 -
Veterinary Medicine and Science May 2020Pain management in veterinary patients is a crucial component of appropriate patient care. Multimodal analgesia that includes both systemically and locally/regionally... (Review)
Review
Pain management in veterinary patients is a crucial component of appropriate patient care. Multimodal analgesia that includes both systemically and locally/regionally administered drugs is generally the most effective approach to providing pain relief. Local anaesthetic drugs used in local and regional blockade are unique in that they can completely block the transmission of pain (in conscious patients) or nociceptive (in anaesthetized patients) signals, thereby providing profound analgesia. In addition, local and regional administration of drugs, when compared with systemic bolus administration, generally results in a lower incidence of dose-related adverse effects. Due to the potential to provide profound analgesia and the high safety margin (when used correctly) of this drug class, local anaesthetics are recommended as part of the analgesic protocol in the majority of patients undergoing surgical procedures or suffering traumatic injuries. This manuscript, Part 1 of a two-part instalment, emphasizes the importance of using local and regional anaesthesia as a component of multimodal analgesia, provides a review of the basic pharmacokinetics/pharmacodynamics of local anaesthetic drugs in general, lists information on commonly used local anaesthetic drugs for local and regional blockade in dogs and cats, and briefly introduces the novel liposome-encapsulated bupivacaine (NOCITA®). Part 2 is a review of local and regional anaesthetic techniques used in dogs and cats (Grubb & Lobprise, 2020).
Topics: Anesthesia, Conduction; Anesthesia, Local; Anesthetics, Local; Animals; Bupivacaine; Cats; Dogs; Pain Management
PubMed: 31965742
DOI: 10.1002/vms3.219 -
British Journal of Anaesthesia Apr 2019Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major... (Review)
Review
Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.
Topics: Anesthesia, Caudal; Anesthesiology; Anesthetics, Local; Auscultation; Child; Contraindications, Procedure; Education, Medical, Graduate; Epidural Space; Humans; Pain, Postoperative; Palpation; Ultrasonography, Interventional
PubMed: 30857607
DOI: 10.1016/j.bja.2018.11.030 -
Anaesthesia Mar 2019The American Society of Anesthesiologists (ASA) physical status is a tool commonly used to classify a patient's physical fitness before surgery. Since its introduction... (Review)
Review
The American Society of Anesthesiologists (ASA) physical status is a tool commonly used to classify a patient's physical fitness before surgery. Since its introduction in 1941 it has undergone very few modifications to improve its reliability and to eliminate subjectivity, despite vast changes in both surgical and anaesthetic technique. We present the history of the ASA physical status and review the literature on its applicability to contemporary anaesthetic practice.
Topics: Anesthesiology; Health Status Indicators; Humans; Physical Fitness; Quality Improvement; Societies, Medical; United States
PubMed: 30648259
DOI: 10.1111/anae.14569 -
Die Anaesthesiologie May 2023The reduction of greenhouse gases such as CO emissions and their equivalents (CO2e) generally has three aspects: Fugitive direct emissions (anesthetic gases, exhaust... (Review)
Review
The reduction of greenhouse gases such as CO emissions and their equivalents (CO2e) generally has three aspects: Fugitive direct emissions (anesthetic gases, exhaust gases), indirect emissions through the purchase of energy (electricity, heat) and emissions in the supply chain (supply of consumables, disposal). Since pediatric anesthesia has a traditional affinity with inhalation, the use of anesthetic gases should be repeatedly questioned and, if possible, avoided on the way to net zero emissions in addition to general measures to conserve resources. In children, analgosedation, total intravenous anesthesia (TIVA) and establishment of venous access prior to the induction of anesthesia are particularly suitable for this purpose. In addition to avoiding greenhouse gases, the methods mentioned offer other significant medical advantages and can also be profitable in terms of safety and comfort. Nevertheless, anesthetic gases are required in pediatric anesthesia in some situations. For this reason, it is important to save anesthetic gases through minimal fresh gas flow and a rational approach to inhalation induction. To facilitate implementation in clinical practice, this article provides recommendations for mask induction and choice of anesthetic procedure.
Topics: Humans; Child; Anesthetics, Inhalation; Greenhouse Gases; Anesthesia, General; Anesthesiology
PubMed: 36988636
DOI: 10.1007/s00101-023-01270-8 -
British Journal of Anaesthesia May 2022The choice of anaesthetic may influence regulation of renal perfusion and function. We investigated renal function in patients anaesthetised with propofol or sevoflurane... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The choice of anaesthetic may influence regulation of renal perfusion and function. We investigated renal function in patients anaesthetised with propofol or sevoflurane before surgery and postoperatively.
METHODS
Patients with ASA physical status 1-2 planned for spinal surgery were randomised to propofol or sevoflurane anaesthesia. Blood and urine were collected before anaesthesia, during anaesthesia (before surgery), during postoperative care, and the day after surgery.
RESULTS
Twenty-seven patients completed the study protocol (average age, 51 yr; average BMI, 28 kg m) and 11 were women. Urine output and sodium excretion were lower during sevoflurane anaesthesia (n=14) than during propofol anaesthesia (n=13) (0.3 vs 1.1 ml kg h [P=0.01] and 2.6 vs 6.0 mmol h [P=0.04], respectively). Urinary potassium excretion was lower during anaesthesia than after, without intergroup difference (2.3 vs 5.7 mmol h, P<0.001). Sevoflurane anaesthesia increased plasma renin compared with baseline (138 vs 23 mIU L, P<0.001) and propofol anaesthesia (138 vs 27 mIU L, P=0.008). Plasma arginine-vasopressin did not change significantly during anaesthesia, but was elevated postoperatively compared with baseline irrespective of anaesthetic (21 vs 12 ng L, P=0.02). Sevoflurane caused higher postoperative plasma creatinine than propofol (83 vs 66 mmol L, P=0.01). Kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin did not change significantly in either group.
CONCLUSIONS
Sevoflurane anaesthesia reduced urine output and sodium excretion and increased plasma renin compared with propofol anaesthesia. The impact of this on acute kidney injury and fluid resuscitation during surgery warrants further investigation.
CLINICAL TRIAL REGISTRATION
EudraCT: 2017-001646-10; Clinicaltrials.gov: NCT0333680.
Topics: Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Female; Humans; Kidney; Male; Methyl Ethers; Middle Aged; Propofol; Renin; Sevoflurane; Sodium
PubMed: 35279277
DOI: 10.1016/j.bja.2022.02.030 -
European Journal of Anaesthesiology Jun 2023HSK3486 (ciprofol) is a 2,6-disubstituted phenol derivative that acts like propofol as an agonist at the gamma-aminobutyric acid-A (GABA A ) receptor. (Randomized Controlled Trial)
Randomized Controlled Trial
Efficacy and safety of ciprofol vs. propofol for the induction and maintenance of general anaesthesia: A multicentre, single-blind, randomised, parallel-group, phase 3 clinical trial.
BACKGROUND
HSK3486 (ciprofol) is a 2,6-disubstituted phenol derivative that acts like propofol as an agonist at the gamma-aminobutyric acid-A (GABA A ) receptor.
OBJECTIVE
To investigate the efficacy and safety of HSK3486 for general anaesthesia induction and maintenance.
DESIGN
A single-blinded, randomised, parallel-group, phase 3 trial.
SETTING
Involving 10 study centres, from November 24, 2020 to January 25, 2021.
PATIENTS
A total of 129 patients undergoing nonemergency, noncardiothoracic, and nonneurosurgical elective surgery.
INTERVENTION
Patients were randomly assigned at a 2:1 ratio into HSK3486 or propofol groups, to receive HSK3486 (0.4 mg kg -1 ) or propofol (2.0 mg kg -1 ) for induction before a maintenance infusion at initial rates of 0.8 and 5.0 mg kg -1 h -1 , and were adjusted to maintain a bispectral index (BIS) of 40-60 until the end of surgery.
MAIN OUTCOME MEASURES
Noninferiority between the drugs was evaluated as the lower limit of the 95% confidence interval (CI) for the between-group difference in the success rate of anesthetic maintenance (primary outcome) >-8%. Secondary outcomes included successful anaesthetic induction, full alertness and spontaneous breathing recovery, time until leaving the postanaesthesia care unit and changes in BIS. Safety profiles were also measured.
RESULTS
Of 129 enrolled patients, 128 completed the trial, with 86 in the HSK3486 group and 42 in the propofol group. The success rate for the maintenance of general anaesthesia was 100% for both groups, and noninferiority of HSK3486 was confirmed (95% CI -4.28% to 8.38%). No significant differences were found between the two groups of patients with regard to secondary outcomes (all P > 0.05). There appeared to be a comparable incidence of treatment for emergency adverse events (TEAEs) (80.2% vs. 81.0%, P = 1.000) and drug-related TEAEs (57.0% vs. 64.3%, P = 0.451) in the HSK3486 and propofol groups.
CONCLUSION
HSK3486 had a noninferior efficacy profile compared to propofol, exhibiting excellent tolerance.
TRIAL REGISTRATION
Clinicaltrials.gov, identifier: NCT04511728.
Topics: Humans; Propofol; Single-Blind Method; Anesthesia, General; Anesthetics; Elective Surgical Procedures; Anesthetics, Intravenous
PubMed: 36647565
DOI: 10.1097/EJA.0000000000001799