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British Journal of Anaesthesia Aug 2023The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global...
The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global expansion of preoperative anaemia treatment programmes, including misconceptions about the true cost/benefit ratio for patient care and health system economics. Institutional investment and buy-in from stakeholders could lead to significant cost savings through avoided complications of anaemia and red blood cell transfusions, and through containment of direct and variable costs of blood bank laboratories. In some health systems, billing for iron infusions could generate revenue and promote growth of treatment programmes. The aim of this work is to galvanise integrated health systems worldwide to diagnose and treat anaemia before major surgery.
Topics: Humans; Anemia; Iron; Erythrocyte Transfusion; Costs and Cost Analysis; Preoperative Care
PubMed: 37244835
DOI: 10.1016/j.bja.2023.04.038 -
Current Opinion in Anaesthesiology Jun 2024Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly... (Review)
Review
PURPOSE OF REVIEW
Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications.
RECENT FINDINGS
Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period.
SUMMARY
Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.
Topics: Humans; Obesity; Anesthesia; Postoperative Complications; Preoperative Care; Positive-Pressure Respiration; Perioperative Care; Airway Management
PubMed: 38573180
DOI: 10.1097/ACO.0000000000001377 -
The British Journal of Surgery Nov 2023Recent studies have demonstrated that prehabilitation improves patients' physical fitness but its impact on postoperative morbidity remains unclear. This study aimed to... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Recent studies have demonstrated that prehabilitation improves patients' physical fitness but its impact on postoperative morbidity remains unclear. This study aimed to assess the effect of personalized, multimodal, semisupervised, home-based prehabilitation on postoperative complications after surgery for gastric cancer.
METHODS
This RCT was conducted at two centres in Lithuania. Patients (aged at least18 years) with gastric cancer scheduled to undergo elective primary surgery or surgery after neoadjuvant chemotherapy for gastric cancer were randomized (1 : 1) to prehabilitation or standard care. Prehabilitation included exercise interventions focused on endurance, respiratory muscle strength, stretching, and resistance training as well as nutritional and psychological support. The primary outcome was the proportion of patients with postoperative complications within 90 days after surgery. Secondary outcomes included 90-day mortality rate, physical condition, fitness level, nutritional status, quality of life, anxiety and depression level, and proportion of patients completing neoadjuvant chemotherapy.
RESULTS
Between February 2020 and September 2022, 128 participants were randomized to prehabilitation (64) or standard care (64), and 122 (prehabilitation 61, control 61) were analysed. The prehabilitation group had increased physical capacity before the operation compared with baseline (mean 6-min walk test change +31 (95 per cent c.i. 14 to 48) m; P = 0.001). The prehabilitation group had a decreased rate of non-compliance with neoadjuvant treatment (risk ratio (RR) 0.20, 95 per cent c.i. 0.20 to 0.56), a 60 per cent reduction in the number of patients with postoperative complications at 90 days after surgery (RR 0.40, 0.24 to 0.66), and improved quality of life compared with the control group.
CONCLUSION
Prehabilitation reduced morbidity in patients who underwent gastrectomy for gastric cancer.
REGISTRATION NUMBER
NCT04223401 (http://www.clinicaltrials.gov).
Topics: Humans; Preoperative Exercise; Quality of Life; Stomach Neoplasms; Preoperative Care; Postoperative Complications
PubMed: 37750588
DOI: 10.1093/bjs/znad312 -
American Journal of Infection Control Nov 2023Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and...
BACKGROUND
Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections.
METHODS
A PubMed search was performed to update the evidence on skin antiseptic products and practices.
RESULTS
Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs.
CONCLUSIONS
Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.
Topics: Male; Humans; Soaps; Anti-Infective Agents, Local; Chlorhexidine; Povidone-Iodine; Antisepsis; Anti-Infective Agents; Surgical Wound Infection; Ethanol; Skin; Preoperative Care; 2-Propanol
PubMed: 37890954
DOI: 10.1016/j.ajic.2023.02.002 -
The Journal of International Medical... May 2024The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years... (Review)
Review
The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years there has been an increase in the application of frailty indices. Multiple scales have emerged that can be applied in the perioperative setting. Each one has demonstrated some utility, either by way of establishing postoperative prognosis or as a method for the clinical optimization of patient care. Anaesthesiologists are offered a wide choice of scales, the characteristics and appropriate management of which they are often unaware. This narrative review aims to clarify the concept of frailty, describe its importance in the perioperative setting and evaluate the different scales that are most applicable to the perioperative setting. It will also establish paths for the future optimization of patient care.
Topics: Humans; Frailty; Geriatric Assessment; Aged; Frail Elderly; Prognosis; Preoperative Care; Preoperative Period
PubMed: 38818532
DOI: 10.1177/03000605241251705 -
Expert Review of Endocrinology &... 2023Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important... (Review)
Review
INTRODUCTION
Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.
AREAS COVERED
A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.
EXPERT OPINION
The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.
Topics: Humans; Diabetes Mellitus; Hyperglycemia; Preoperative Care; Glucose
PubMed: 37937905
DOI: 10.1080/17446651.2023.2272865 -
Anesthesiology Clinics Mar 2024Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are... (Review)
Review
Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.
Topics: Humans; Social Determinants of Health; Social Factors; Preoperative Care; Anesthesiology; Anesthesiologists
PubMed: 38278595
DOI: 10.1016/j.anclin.2023.07.002 -
Current Problems in Cancer Oct 2023In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care...
In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care principles such as complex symptom management, high-risk decision-making and communication have played an important role in preoperative discussions of oncologic surgery for both palliative and curative intent. There is increasing motivation among surgeons to integrate palliative care into the perioperative period in order to more effectively and comprehensively address potential adverse functional and quality of life outcomes. We discuss how the concept of frailty, and various instruments to measure frailty, have impacted perioperative decision-making, review the roots of surgical risk stratification and counseling on acceptable perioperative risk, and explore the preoperative setting as a possible avenue by which primary and specialty palliative care integration may have beneficial impact for patients considering oncologic resections.
Topics: Humans; Frailty; Palliative Care; Quality of Life; Surgical Oncology; Preoperative Care
PubMed: 37865539
DOI: 10.1016/j.currproblcancer.2023.101021 -
Ugeskrift For Laeger Jan 2024With an increasing aging population, there will be a greater need for cancer evaluation and treatment in older patients. Age alone is not a good predictor of... (Review)
Review
With an increasing aging population, there will be a greater need for cancer evaluation and treatment in older patients. Age alone is not a good predictor of postoperative morbidity, and a multidisciplinary approach is crucial for managing comorbidities. Preoperative optimisation, such as prehabilitation, may in some cases reduce postoperative complications, and minimal invasive techniques should be preferred whenever possible. In general, as summarised in this review, cancer treatment in older patients should be individualised based on comorbidities and life expectancy.
Topics: Humans; Aged; Preoperative Care; Postoperative Complications; Neoplasms; Aging; Morbidity
PubMed: 38305320
DOI: 10.61409/V08230489 -
European Journal of Surgical Oncology :... May 2024Prehabilitation is an intervention that occurs between cancer diagnosis and the start of an acute treatment. It involves physical, nutritional, and psychological... (Review)
Review
Prehabilitation is an intervention that occurs between cancer diagnosis and the start of an acute treatment. It involves physical, nutritional, and psychological assessments to establish a baseline functional level and provide targeted interventions to improve a person's health and prevent future impairments. Prehabilitation has been applied to surgical oncology and has shown positive results at improving functional capacity, reducing hospital stay, decreasing complications, and enhancing health-related quality of life. The importance of collaboration between various healthcare professionals and the implementation of multimodal interventions, including exercise training, nutrition optimization, and emotional support is discussed in this manuscript. The need for screening and assessment of conditions such as sarcopenia, frailty, or low functional status in order to identify patients who would benefit the most from prehabilitation is vital and should be a part of all prehabilitation programs. Exercise and nutrition play complementary roles in prehabilitation, enhancing anabolism and performance. However, in the presence of malnutrition and sarcopenia, exercise-related energy expenditure without sufficient protein intake can lead to muscle wasting and further deterioration of functional capacity, thus special emphasis on nutrition and protein intake should be made in these cases. Finally, the challenges and the need for a paradigm shift in perioperative care are discussed to effectively implement personalized prehabilitation programs.
Topics: Humans; Preoperative Exercise; Neoplasms; Sarcopenia; Quality of Life; Frailty; Nutritional Status; Malnutrition; Preoperative Care; Nutrition Assessment
PubMed: 37451924
DOI: 10.1016/j.ejso.2023.07.005