Early Antibiotics & Fluids Key in Sepsis Management

Sepsis and septic shock are medical emergencies that require immediate action | Anesthesiology News

Early resuscitation should begin with early antibiotics and fluids, as well as the identification of the source of infection, according to new guidelines that were released at the Society of Critical Care Medicine’s (SCCM) 2017 Critical Care Congress.

In addition, the new guidelines say a health care provider who is trained and skilled in the management of sepsis should reassess the patient frequently at the bedside. “It is not the initial assessment, but the frequent reassessment that will make a difference,” said Andrew Rhodes, MD, FRCP, FRCA, FFICM, the co-chair of the guidelines committee.

Read the full news story here

Management of major trauma

Trauma remains one of the leading causes of mortality and morbidity in the UK | Anaesthesia and Intensive Care Medicine

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Trauma is the primary cause of mortality in the first four decades of life and has a significant impact on the economy of the nation. In recent years the structure of trauma care has undergone significant restructuring. This article will review the reports that led to these changes, discuss the changes that have occurred and describe some of the anaesthetic management of this important group of patients.

Full reference: pearson, J. et al. (2017) Management of major trauma. Anaesthesia and Intensive Care Medicine. Published online: June 24, 2017

 

Anesthesiology: July 2017 Podcast

New Issue of Anesthesiology
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Image source: Anesthesiology

On the cover:
Management of perioperative fluid impacts gastrointestinal function. In this issue of Anesthesiology, Gómez-Izquierdo et al. randomized patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program to receive intraoperative goaldirected fluid therapy or fluid therapy based on traditional principles and assessed the impact on postoperative ileus. Intraoperative goal-directed fluid therapy did not reduce postoperative ileus, suggesting that previously demonstrated benefits might have been offset by advancements in perioperative care.

The potential for big data analytics to enhance our knowledge of the complex regional pain syndromes

In an era of expanding costs and declining reimbursement, the healthcare industry has dramatically expanded the collection of demographic and clinical data to facilitate billing efficiency and maintain financial solvency | Journal of Clinical Anesthesia

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Electronic health data collection has primarily emphasized the capture of diagnostic coding, medication delivery, laboratory utilization, and procedural interventions to support third party reimbursement claims, improve efficiency, and provide transparency. Although much of the electronic stored data was never directly intended to answer clinical questions, or guide clinical care, the use of data analytics has created opportunities to winnow through the vast data collections and pull out useful insights into previously unrecognized patterns of common and uncommon medical disorders

Full reference: Burgess, F. & Fragoza, K. (2017) Fishing for answers in an ocean of data: The potential for big data analytics to enhance our knowledge of the complex regional pain syndromes. Journal of Clinical Anesthesia. Volume 40. pp. 117–118

Confronting the Perioperative Pain Paradox

Pain medications, especially opioids, have understandably undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs | Anesthesiology News

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The problem with eliminating opioid use is that major surgery comes with major pain, and opioids are effective at treating major pain. Furthermore, when opioids are finally introduced after attempting to avoid their use, it is usually done “emergently”—only after the patient is in extreme, inconsolable pain that disrupts recovery. This will likely lead to giving patients larger doses and increasing the risk for adverse events that we are all trying to avoid.

Note that severe acute pain is a risk factor for the development of chronic pain, sleep disturbances, changes in mood and behavior (especially in children), poor wound healing and delayed recovery. This avoidance of opioids in the face of intense pain due to their potential short- and long-term negative effects has created, what I call, the “perioperative pain paradox.”

Full reference: Answine, J.F. (2017) Confronting the Perioperative Pain Paradox. Anesthesiology News. Published online: 15 June 2017

A survey of UK peri-operative medicine: pre-operative care

A.-M. Bougeard et al.  A survey of UK peri-operative medicine: pre-operative care. Anaesthesia.  published online 14th June 2017.

Summary
The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115).

They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%).

Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%) had clinics for high-risk surgical patients. However, 80 (93%) expressed a desire for support and training in shared decision-making.

We asked about management of pre-operative anaemia, and identified that 69 (80%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively.

A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%) respondents indicated that they had access to specific interventions.

Respondents were asked to rank their ‘top five’ priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction ; and primary care collaboration.

We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

Nurses’ experiences of pain management for people with advanced dementia approaching the end of life

Pain management in end-stage dementia is a fundamental aspect of end-of-life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care | Journal of Clinical Nursing

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Aims and objectives: To explore hospice, acute care and nursing home nurses’ experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

 

Conclusions: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

Relevance to clinical practice: Nurses considered pain management fundamental to end-of-life care provision; however, nurses working in acute care and nursing home settings may be undersupported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology.

Full reference: De Witt Jansen, B. et al. Nurses’ experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study. Journal of Clinical Nursing. 26,(9-10) pp. 1234–1244