Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no ...opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.
This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines ...are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 5-HT3 receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1).Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago; a guideline published by American Society of Health System Pharmacists in 1999; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada, the Association of Paediatric Anaesthetists of Great Britain & Ireland and the Association of Perianesthesia Nursing; and several guidelines published in other languages.The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways.The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations or do not address all aspects of PONV management. The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.
Objective
The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American ...Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.
Methods
Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
Results
New or updated topics in this CPG include: contextualization in an adiposity‐based chronic disease complications‐centric model, nuance‐based and algorithm/checklist‐assisted clinical decision‐making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Conclusions
Bariatric procedures remain a safe and effective intervention for higher‐risk patients with obesity. Clinical decision‐making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
Background
This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing ...recommendations for each ERAS item within the ERAS® protocol.
Methods
A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.
Results
The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.
Conclusion
A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
Emerging roles of liposomal bupivacaine in anesthesia practice Malik, Obaid; Kaye, Alan D; Kaye, Aaron ...
Journal of Anaesthesiology-Clinical Pharmacology/Journal of anaesthesiology clinical pharmacology,
04/2017, Letnik:
33, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Despite advances in drug technology and improvements in technology, including peripheral nerve catheters and ultrasound, postoperative pain is still a significant problem in the clinical setting ...worldwide. Postoperative pain can have a critical negative impact with regard to physiological consequences to the body and therefore, the role of liposomal bupivacaine as an extended release bupivacaine with approximately 72 h of duration may have far-reaching and significant impact in clinical practice. Liposomal bupivacaine has a DepoFoam multivesicular liposome technology with particle suspension in an isotonic aqueous solution and consists of tiny lipid-based particles, which contain discrete water-filled chambers dispersed through a lipid matrix. Other advantages include a reduction in opioid consumption, while not requiring a catheter or any other device, as well as easy dilution with saline. This review summarizes current research with this novel agent in postsurgical pain, and discusses potential roles in chronic pain states. Further studies are warranted for its use in epidural and intrathecal administration. Moreover, this review will explore the expansion of liposomal bupivacaine's current clinical role.
BACKGROUND:Although previous publications suggest an increasing demand and volume of nonoperating room anesthesia (NORA) cases in the United States, there is little factual information on either ...volume or characteristics of NORA cases at a national level. Our goal was to assess the available data using the National Anesthesia Clinical Outcomes Registry (NACOR).
METHODS:We performed a retrospective analysis of NORA volume and case characteristics using NACOR data for the period 2010–2014. Operating room (OR) and NORA cases were assessed for patient, provider, procedural, and facility characteristics. NACOR may indicate general trends, since it collects data on about 25% of all anesthetics in the United States each year. We examined trends in the annual proportion of NORA cases, the annual mean age of patients, the annual proportions of American Society of Anesthesiologists physical status (ASA PS) III–V patients, and outpatient cases. Regression analyses for trends included facility type and urban/rural location as covariables. The most frequently reported procedures were identified.
RESULTS:The proportion of NORA cases overall increased from 28.3% in 2010 to 35.9% in 2014 (P < .001). The mean age of NORA patients was 3.5 years higher compared with OR patients (95% CI 3.5–3.5, P < .001). The proportion of patients with ASA PS class III–V was higher in the NORA group compared with OR group, 37.6% and 33.0%, respectively (P < .001). The median (quartile 1, 3) duration of NORA cases was 40 (25, 70) minutes compared with 86 (52, 141) minutes for OR cases (P < .001). In comparison to OR cases, more NORA cases were started after normal working hours (9.9% vs 16.7%, P < .001). Colonoscopy was the most common procedure that required NORA. There was a significant upward trend in the mean age of NORA patients in the multivariable analysis—the estimated increase in mean age was 1.06 years of age per year of study period (slope 1.06; 95% confidence interval CI 1.05–1.07, P < .001). Multivariable analysis demonstrated that the mean age of NORA patients increased significantly faster compared with OR patients (difference in slopes 0.39; 95% CI 0.38–0.41, P < .001). The annual increase in ordinal ASA PS of NORA patients was small in magnitude, but statistically significant (odds ratio 1.03; 95% CI 1.03–1.03, P < .001). The proportion of outpatient NORA cases increased from 69.7% in 2010 to 73.3% in 2014 (P < .001).
CONCLUSIONS:Our results demonstrate that NORA is a growing component of anesthesiology practice. The proportion of cases performed outside of the OR increased during the study period. In addition, we identified an upward trend in the age of patients receiving NORA care. NORA cases were different from OR cases in a number of aspects. Data collected by NACOR in the coming years will further characterize the trends identified in this study.
Goal-directed fluid therapy in the perioperative setting Kendrick, Julia; Kaye, Alan; Tong, Yiru ...
Journal of Anaesthesiology-Clinical Pharmacology/Journal of anaesthesiology clinical pharmacology,
04/2019, Letnik:
35, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in ...significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a "zero-balance" approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.
Neuraxial anesthesia use in cesarean deliveries (CDs) has been rising since the 1980s, whereas general anesthesia (GA) use has been declining. In this brief report we analyzed recent obstetric ...anesthesia practice patterns using National Anesthesiology Clinical Outcomes Registry data. Approximately 218,285 CD cases were identified between 2010 and 2015. GA was used in 5.8% of all CDs and 14.6% of emergent CDs. Higher rates of GA use were observed in CDs performed in university hospitals, after hours and on weekends, and on patients who were American Society of Anesthesiologists class III or higher and 18 years of age or younger.
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