Perioperative care of the obese patient Carron, M.; Safaee Fakhr, B.; Ieppariello, G. ...
British journal of surgery,
January 2020, 2020-Jan, 20200101, Letnik:
107, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Background
Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable ...future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.
Methods
A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta‐analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non‐obese populations were used.
Results and conclusion
Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.
Antecedentes
La obesidad se ha convertido en un problema creciente en todo el mundo en las últimas décadas. Por lo tanto, cirujanos y anestesistas tratarán un número creciente de pacientes obesos en el futuro próximo y deberían estar preparados para proporcionar un tratamiento óptimo para estas personas. Esta revisión proporciona una actualización de la evidencia reciente respecto a las estrategias perioperatorias para pacientes obesos.
Métodos
Se llevó a cabo una búsqueda de los artículos sobre cuidados perioperatorios de pacientes obesos (lengua inglesa únicamente) en julio 2019 utilizando las bases de datos electrónicas PubMed, Google Scholar, Scopus, Web of Science y Cochrane Library. La revisión se centró en los resultados de ensayos aleatorizados y controlados, aunque se consideraron también estudios observacionales, metaanálisis, revisiones, guías clínicas, y otros artículos que discutían el cuidado perioperatorio de los pacientes obesos. Cuando los datos de los pacientes obesos no estaban disponibles, se utilizaron datos relevantes de las poblaciones no obesas.
Resultados y conclusión
Los pacientes obesos requieren una evaluación preoperatoria integral. Los resultados postoperatorios se pueden mejorar mediante la presencia de equipos médicos con experiencia, equipamiento y monitorización apropiada, manejo anestésico cuidadoso, y una adecuada estrategia de ventilación perioperatoria. Son necesarias precauciones adicionales durante el periodo perioperatorio en pacientes con obesidad mórbida severa, síndrome metabólico, síndrome de apnea obstructiva del sueño severa o no tratada, síndrome de hipoventilación y obesidad, pacientes que reciben soporte ventilatorio domiciliario o tratamiento postoperatorio con opioides; y pacientes obesos sometidos a cirugía abierta, procedimientos largos o cirugía de revisión.
Preoperative evaluation of obese patients is recommended. Investigation should focus on identifying and treating obesity‐ and non‐obesity‐related conditions that may affect the perioperative course. Proper patient positioning, the right approach to airway management, an adequate ventilation strategy, careful anaesthetic management, multimodal analgesia and optimal postoperative care improve outcomes in obese patients undergoing surgery.
Preoperative preparation critical
...resistance training guidance is limited to frequency, with no detail on necessary characteristics of resistance training prescription (eg. external load, repetitions, rest breaks). ...the purpose ...of this systematic review was to bring together the evidence on resistance training during pregnancy for critical review to identify resistance training characteristics and their reporting frequency, and explore variability among these reported characteristics. Original research papers reporting any resistance training intervention (standalone or concurrent) during pregnancy were included. Discussion: This systematic review shows that frequency, intensity, and duration were consistently reported, however, there was considerable variability in the level of detail in reporting as well as variability among the resistance training prescriptions.
General anaesthesia should prevent patients from experiencing surgery, defined as connected consciousness. The isolated forearm technique (IFT) is the current gold standard for connected ...consciousness monitoring. We evaluated the efficacy of different anaesthesia regimens in preventing IFT responses.
We conducted a systematic review with meta-analysis of studies evaluating IFT in adults. Proportions of IFT-positive patients were compared for inhalational versus intravenous anaesthesia and anaesthesia brain monitor (ABM)-guided versus non-ABM-guided.
Of 1131 patients in 22 studies, 393 (34.8%) had an IFT response during induction or maintenance. IFT-positive patients were less frequent during induction (19.7% 95% CI, 17.5–22.1) than during maintenance (31.2% 95% CI, 27.8–34.8). Proportions of IFT-positive patients during induction and maintenance were similar for inhalational (0.51 95% CI, 0.38–0.65) and intravenous (0.52 95% CI, 0.26–0.77) anaesthesia, but during maintenance were lower with inhalational (0.18 95% CI, 0.08–0.38) than with intravenous (0.48 95% CI, 0.24–0.73) anaesthesia. Proportions of IFT-positive patients during induction and maintenance were not significantly different for ABM-guided (0.64 95% CI, 0.39–0.83) and non-ABM-guided (0.48 95% CI, 0.34–0.62) anaesthesia but during maintenance were lower with non-ABM-guided (0.19 95% CI, 0.09–0.37) than with ABM-guided (0.57 95% CI, 0.34–0.77). Proportions of IFT-positive patients decreased significantly with increasing age and premedication use. Of the 34 anaesthesia regimens, 16 were inadequate. Studies had low methodological quality (only seven randomised controlled trials) and significant heterogeneity.
Standard general anaesthesia regimens might not prevent connected consciousness. More accurate anaesthesia brain monitor methodology to reduce the likelihood of connected consciousness is desirable.
Introduction: Periodic testing is essential to evaluate changes in key physical and physiological characteristics in response to development strategies employed with adolescent rugby league players; ...however, the retest reliability of scientifically popular tests to assess these characteristics are yet to be comprehensively examined in this population. ...the aim of this study was to determine the retest reliability of the most commonly used tests in the literature, to assess key physical and physiological characteristics in adolescent, male rugby league players. Tests used to assess physiological characteristics demonstrated moderate to excellent ICC, with CV <5% including: linear speed, ICC=0.794, CV=1.35%; change-of-direction speed, ICC=0.787–0.860, CV=1.85–2.07%; aerobic capacity, ICC=0.854, CV=3.42%; muscular power, ICC=0.733–0.874, CV=3.72–4.02%; and muscular strength, ICC=0.944–0.988, CV=1.08–2.56%.
Key physical characteristics identified in rugby league are height, body mass, and body composition, while key physiological characteristics are muscular power, muscular strength, linear speed, ...change-of-direction speed, and aerobic capacity. Discussion: This systematic review provides the most comprehensive identification of tests commonly used to assess key physical and physiological characteristics among adolescent, male rugby league players. Given the studies included in our review contain rationale for test selection and undergo expert scrutiny prior to publication, the identified tests hold scientific merit, and the largest pool of outcome data for future comparisons.
Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of ...reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.
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