Current anaesthesia and critical care最新文献

HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome has been recognised as a life threatening complication of pregnant women for many years. The majority of women with HELLP syndrome have hypertension and proteinuria which may be absent in 10–20% of cases–referred to as atypical HELLP. A primigravida received epidural labour analgesia and she continued to bleed from the skin puncture site. Evaluation for the cause of bleed established the diagnosis of atypical HELLP syndrome. Although rarely encountered, an atypical HELLP may have dangerous anaesthetic consequences when clinicians are caught unawares. We report one such case with atypical presentation.

Reliable and valid measures of risk and outcome are essential prerequisites for the effective monitoring of outcome following surgery and the evaluation of innovations in perioperative care. Enhanced Recovery (ER) programs raise the exciting prospect of reduced resource utilisation in combination with improved (or at least equivalent) outcomes. Careful monitoring of process (compliance with ER elements) and outcome are essential if this goal is to be achieved without unintended harm to patients (e.g. increased readmission due to postoperative morbidity arising in the community).

Risk (case-mix) adjustment is necessary to separate the influence of patient and care factors and thereby minimise the effects of case-mix variation on evaluation of care quality. Outcome measures that are useful when evaluating ER programs include: length of hospital stay, readmission rate, total hospital stay, morbidity/complications, patient reported outcome measures and death. Description of postoperative morbidity should use validated measures, rather than ad hoc lists of medical diagnoses.

Awareness of enhanced recovery has moved swiftly since the Enhanced Recovery Partnership Programme was launched in 2009 as a joint venture between the Department of Health, NHS Improvement, NHS Institute for Innovation and Improvement, and the national Cancer Action Team.

The innovative approach to elective surgery has demonstrated improved patient experience and clinical outcomes while also achieving efficiency savings, increased quality and productivity, and decreased length of stay.

Enhanced recovery represents a quantum leap in peri-operative management of patients undergoing colorectal surgery. Each of the elements of enhanced recovery are evidence based and together when used in concert provide an easy framework upon which to base future peri-operative care. The following article outlines the facets of enhanced recovery and the evidence base behind them. The role of the anaesthetist is central to the implementation of enhanced recovery and as such particular emphasis is given to fasting guidelines and carbohydrate loading pre-operatively and peri-operative fluid therapy.

The use of enhanced recovery pathways within elective surgery has increased in recent years but uptake outside of specialist centres is still slow, despite the growing evidence base to support their introduction. This article will briefly outline what is meant by an enhanced recovery pathway (ERP) and outline the central characteristics and features which make up an ERP. The procedural details and results of an orthopaedic ERP which has been used in 2391 consecutive hip and knee joint replacement patients at a NHS district general hospital within the United Kingdom will then be outlined.

The results of this unit illustrate that when a standardised, multi-disciplinary pathway is implemented and managed correctly, dramatic reductions to length of stay can be achieved. In combination, high levels of both staff and patient satisfaction are achieved along with good clinical outcomes. It is proposed that if such ways of working are implemented in other hospitals major economic and capacity savings could be realised at the same time as improving patient care.