Current Anesthesiology Reports最新文献

Purpose of review: Preoperative anemia is independently associated with worse postoperative outcomes following cardiac and noncardiac surgery. This article explores the current understanding of perioperative anemia and iron deficiency with reference to definition, diagnosis, and treatment.

Recent findings: Iron deficiency is the most common cause of anemia. It can arise from reduced iron intake, poor absorption, or excess iron loss. Inflammation throughout the preoperative period can drive iron sequestration, leading to a functional deficiency of iron and the development of what was referred to until recently as the "anemia of chronic disease." Current best practice guidance supports the routine administration of preoperative intravenous iron to treat anemia despite limited evidence. This "one size fits all" approach has been called into question following results from a recent large, randomized trial (the PREVENTT trial) that assessed the use of a single dose of intravenous iron compared to placebo 10-42 days before major abdominal surgery. Although there were no improvements in patient-centered outcomes apparent during the initial hospital stay, secondary endpoints of this trial suggested there may be some late benefit after discharge from the hospital (8 weeks postoperatively). This trial raises questions on (1) the mechanisms of iron deficiency in the perioperative patient; (2) the need to reassess our opinions on generic anemia management; and (3) the need to address patient outcomes after discharge from hospital.

Summary: Despite the known associations between preoperative anemia (particularly iron deficiency anemia) and poor postoperative outcome, recent evidence suggests that administering intravenous iron relatively close to surgery does not yield a tangible short-term benefit. This is made more complex by the interplay between iron and innate immunity. Iron deficiency irrespective of hemoglobin concentration may also impact postoperative outcomes. Therefore, further research into associations between iron deficiency and postoperative outcomes, and between postoperative anemia, delayed outcomes (hospital readmission), and the efficacy of postoperative intravenous iron is required.

Purpose of review: Patients with cancer who have high levels of psychological distress have poor treatment compliance and worse outcomes. This "review of reviews" provides a narrative synthesis of the impact of psychological prehabilitation interventions on individuals awaiting cancer surgery.

Recent findings: Twenty reviews of prehabilitation with psychological interventions were identified. There is a trend towards improved psychological outcomes following intervention, particularly when psychologist-led. However, there was considerable heterogeneity within interventions, outcome measures, and timing of assessment precluding numeric synthesis. Methodological limitations including non-blinding, absence of stratification, and underpowered studies were also pervasive.

Summary: Providing psychological support early in the cancer pathway and prior to surgery has the potential to improve psychological health and outcomes. The application of existing knowledge in psycho-oncology, including distress screening, is needed in the prehabilitation setting. Consistent outcome assessments, accurate reporting of intervention components and delivery methods, and a consideration of effective systems and economical implementation strategies would facilitate advancements in this field.

Supplementary information: The online version contains supplementary material available at 10.1007/s40140-021-00505-x.

Purpose of review: This review illustrates the current benefits, limitations, ongoing research, and future paths for Low Titer O Whole Blood compared to Component Therapy in massive transfusion for trauma patients.

Recent findings: Many studies show that compared to Component Therapy, Low Titer O Whole Blood transfusion is associated with better patient outcomes and simplified transfusion logistics among others. There are, however, issues with cost, supply/demand and handling of Whole Blood that limit its use, but experience in the military setting has shown that these limitations can be easily overcome.

Summary: The use of Whole Blood has increased in the civilian trauma population and there is a growing body of evidence to support its current use. More research looking at Whole Blood in females of child-bearing age, pediatric populations, and cold-stored platelets is underway.

Purpose: This article focuses on the following:The importance of prehabilitation in people with cancer and the known and hypothesised benefits.Exploration of the principles that can be used when developing services in the absence of a single accepted model of how these services could be established or configured.Description of approaches and learning in the development and implementation of prehabilitation across three different countries: Canada, the Netherlands and the United Kingdom, based on the authors' experiences and perspectives.

Recent findings: Practical tips and suggestions are shared by the authors to assist others when implementing prehabilitation programmes. These include experience from three different approaches with similar lessons.Important elements include the following: (i) starting with a small identified clinical group of patients to refine and test the delivery model and demonstrate proof of concept; (ii) systematic data collection with clearly identified target outcomes from the outset; (iii) collaboration with a wide range of stakeholders including those who will be designing, developing, delivering, funding and using the prehabilitation services; (iv) adapting the model to fit local situations; (v) project leaders who can bring together and motivate a team; (vi) recognition and acknowledgement of the value that each member of a diverse multidisciplinary team brings; (vii) involvement of the whole team in prehabilitation prescription including identification of patients' levels of risk through appropriate assessment and need-based interventions; (viii) persistence and determination in the development of the business case for sustainable funding; (ix) working with patients ambassadors to develop and advocate for the case for support; and (x) working closely with commissioners of healthcare.

Summary: Principles for the implementation of prehabilitation have been set out by sharing the experiences across three countries. These principles should be considered a framework for those wishing to design and develop prehabilitation services in their own areas to maximise success, effectiveness and sustainability.

Purpose of review: This review highlights the importance of the anesthesia team in minimizing perioperative infection risks and prevention of surgical site infection. Due to the immense financial and patient care burden that results from perioperative infection, a foundational knowledge in preventive measures is essential.

Recent findings: Perioperative infection control, the role of the anesthesia team in reducing infection risk, and more specifically the outsized importance of hand hygiene in this space have become increasingly apparent. Maintenance of workspace cleanliness along with hand hygiene forms the cornerstone of preventing microbial transmission. Unfortunately, improvements around perioperative infection control are lacking.

Summary: The importance of the anesthesia team in maintaining proper hand hygiene, a clean work environment, and appropriate patient conditions to minimize risk of perioperative infection cannot be overstated. Poor clinical outcomes, economic burden, and external pressure from payers highlight the need for anesthesia providers to have an up-to-date knowledge of best practices in this area. In this article, we will review the current recommendations for hand hygiene practices and perioperative infection prevention.

Purpose of review: Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent findings: Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change.

Summary: Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.

Purpose of review: With advances in technology and availability of handheld ultrasound probes, studies are focusing on the perioperative care of patients, but a limited number specifically on trauma patients. This review highlights recent findings from studies using point of care ultrasound (POCUS) to improve the care of trauma patients.

Recent findings: Major findings include the use of POCUS to assess volume status of trauma patients upon arrival to measure the major vasculature. Additionally, several studies have advanced the use of POCUS to identify pneumothorax in trauma patients. Finally, the ASA POCUS certification and ASRA expert guidelines are examples of international organizations establishing guidelines for utilization and training of anesthesiologists in the field of POCUS, which will be discussed.

Summary: Despite the COVID-19 pandemic, and considerable resources being diverted to fight this global healthcare crisis, advances are being made in utilization of POCUS to aid the care of trauma patients.

Purpose of review: Multimodal prehabilitation aims to improve preoperative health in ways that reduce surgical complications and expedite post-operative recovery. However, the extent to which preoperative health has been affected by the COVID-19 pandemic is unclear and evidence for the mitigating effects of prehabilitation in this context has not been elucidated. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. Delayed diagnosis and surgery have caused a backlog of cases awaiting surgery increasing the risk of more complex procedures due to disease progression. Poor fitness and preoperative deconditioning are predictive of surgical complications and may be compounded by pandemic-related restrictions to accessing supportive services. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. This narrative review aims to summarize the understanding of the effects of the COVID-19 pandemic on preoperative health and related behaviors and their implication for the need and delivery for prehabilitation to engender improved surgical outcomes. A literature search of Medline was conducted for articles related to preoperative health, prehabilitation, and surgical outcomes published between December 1, 2020 and January 31, 2021. Additional hand searches for relevant publications within the included literature were also conducted through October 15, 2021.

Recent findings: The COVID-19 pandemic, and measures designed to reduce the spread of the virus, have resulted in physical deconditioning, deleterious dietary changes, substance misuse, and heightened anxiety prior to surgery. Due to the adverse health changes prior to surgery, and often protracted waiting time for surgery, there is likely an elevated risk of peri- and post-operative complications. A small number of prehabilitation services and research programmes have been rapidly adapted or implemented to address these needs.

Summary: During the COVID-19 pandemic to date, people undergoing surgery have faced a triple threat posed by extended wait times for surgery, reduced access to supportive services, and an elevated risk of poor outcomes. It is imperative that healthcare providers find ways to employ evidence-based prehabilitation strategies that are accessible and safe to mitigate the negative impact of the pandemic on surgical outcomes. Attention should be paid to cohorts most affected by established health inequities and further exacerbated by the pandemic.