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1.
Anesth Analg ; 139(3): 459-477, 2024 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-38517760

RESUMEN

This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Glucemia , Consenso , Diabetes Mellitus , Hipoglucemiantes , Atención Perioperativa , Humanos , Procedimientos Quirúrgicos Ambulatorios/normas , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Glucemia/efectos de los fármacos , Glucemia/metabolismo , Diabetes Mellitus/sangre , Diabetes Mellitus/tratamiento farmacológico , Atención Perioperativa/normas , Atención Perioperativa/métodos , Hipoglucemiantes/uso terapéutico , Hipoglucemiantes/efectos adversos , Anestesia/normas , Anestesia/efectos adversos , Anestesia/métodos , Sociedades Médicas/normas , Adulto , Anestesiología/normas , Anestesiología/métodos , Insulina/uso terapéutico , Insulina/administración & dosificación , Hipoglucemia/sangre , Hipoglucemia/inducido químicamente , Hipoglucemia/prevención & control , Control Glucémico/normas
2.
Anesthesiology ; 138(2): 132-151, 2023 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-36629465

RESUMEN

These practice guidelines are a modular update of the "Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.


Asunto(s)
Anestesiólogos , Goma de Mascar , Humanos , Niño , Cuidados Preoperatorios/métodos , Ayuno , Procedimientos Quirúrgicos Electivos
3.
Anesth Analg ; 137(6): 1149-1153, 2023 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-37973129

RESUMEN

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.


Asunto(s)
Anestesia , Anestesiología , Humanos , Quirófanos , Enfermedad Crítica , Anestesia/métodos , Atención al Paciente
4.
Anesthesiology ; 136(1): 31-81, 2022 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-34762729

RESUMEN

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.


Asunto(s)
Manejo de la Vía Aérea/normas , Anestesiólogos/normas , Guías de Práctica Clínica como Asunto/normas , Sociedades Médicas/normas , Manejo de la Vía Aérea/métodos , Humanos , Intubación Intratraqueal/métodos , Intubación Intratraqueal/normas , Estados Unidos/epidemiología
5.
Anesth Analg ; 135(1): 198-208, 2022 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-35544755

RESUMEN

In 2009, the Center for Medicare and Medicaid Services (CMS) issued the §482.52 Condition of Participation (CoP) that the director of anesthesia services (DAS) is responsible for all anesthesia administered in the hospital, including moderate and deep procedural sedation provided by nonanesthesiologists. Although this mandate was issued several years ago, many anesthesiology departments remain uncertain as to how best to implement it, who needs to be involved, what resources are needed, and how to leverage this oversight to improve quality of care and patient safety. This article reviews the CMS CoP interpretive guidelines and other regulations as they relate to procedural sedation, outlines the components and benefits of anesthesiology oversight, and describes the tools and structure to implement these guidelines. In addition, we discuss some of the challenges surrounding this implementation. This initiative continues to evolve and expand as needs change and experience develops.


Asunto(s)
Anestesia , Anestesiología , Anciano , Centers for Medicare and Medicaid Services, U.S. , Humanos , Medicaid , Medicare , Estados Unidos
6.
Anesth Analg ; 133(1): 274-283, 2021 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-34127591

RESUMEN

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.


Asunto(s)
Anestesia/normas , Anestesiólogos/normas , Consenso , Atención Perioperativa/normas , Procedimientos de Cirugía Plástica/normas , Sociedades Médicas/normas , Anestesia/métodos , Testimonio de Experto , Cabeza/cirugía , Humanos , Cuello/cirugía , Atención Perioperativa/métodos , Procedimientos de Cirugía Plástica/métodos
7.
Curr Opin Anaesthesiol ; 34(4): 455-463, 2021 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-34148971

RESUMEN

PURPOSE OF REVIEW: Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. RECENT FINDINGS: We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. SUMMARY: The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.


Asunto(s)
Anestesia , Anestesiología , Neumología , Anestesiólogos , Broncoscopía , Humanos
8.
Prague Med Rep ; 122(2): 61-72, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34137682

RESUMEN

Extracorporeal life support has been increasingly utilized in different clinical settings to manage either critical respiratory or heart failure. Complex airway surgery with significant or even total perioperative airway obstruction represents an indication for this technique to prevent/overcome a critical period of severe hypoxaemia, hypoventilation, and/or apnea. This review summarizes the current published scientific evidence on the utility of extracorporeal respiratory support in airway obstruction associated with hypoxaemia, describes the available methods, their clinical indications, and possible limitations. Extracorporeal membrane oxygenation using veno-arterial or veno-venous mode is most commonly employed in such scenarios caused by endoluminal, external, or combined obstruction of the trachea and main bronchi.


Asunto(s)
Obstrucción de las Vías Aéreas , Oxigenación por Membrana Extracorpórea , Adulto , Obstrucción de las Vías Aéreas/etiología , Obstrucción de las Vías Aéreas/terapia , Humanos
9.
Anaesthesia ; 79(10): 1013-1016, 2024 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-39073132
10.
Anesthesiology ; 139(6): 905-907, 2023 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-37756540
12.
Laryngoscope ; 2024 Sep 07.
Artículo en Inglés | MEDLINE | ID: mdl-39243216

RESUMEN

INTRODUCTION: High-flow nasal oxygen (HFNO), or transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), is a technique providing apneic oxygenation and a degree of ventilation during microlaryngeal surgery. Its use with laser has been questioned due to concern for airway fire. For fire to occur, a triad of ignition source, oxidizer, and fuel source must be present. By using HFNO and eliminating an endotracheal tube (fuel source), it is hypothesized that airway fire risk is minimal. We tested this theory with human cadavers using HFNO with increasing levels of FiO2 while performing microlaryngeal laser surgery. METHODS: HFNO was placed on two cadavers, and oxygen was administered at incrementally increasing fraction of inspired oxygen (FiO2) concentrations (30%-100%). Laryngeal microsurgery was conducted with CO2 and KTP lasers applied for 30 s. Oxygen readings were taken at several anatomic locations along the body assessing oxygen concentrations in correlation with increasing FiO2 administration. RESULTS: The use of CO2 and KTP laser on cadaveric vocal folds produced char but no spark or airway fire at any of the tested oxygen concentrations. Apart from the mouth, there was minimal increase in oxygen levels at the surrounding anatomic sites despite elevating FiO2 levels. CONCLUSION: HFNO may be safe to use during microlaryngeal laser surgery. By eliminating the endotracheal tube as a fuel source, risk of airway fire may be negligible. Our study safely applied CO2 and KTP lasers for an uninterrupted 30 s with HFNO at 70 L/min and 100% FiO2 producing no spark or fire. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

13.
Anesth Analg ; 116(5): 1116-1122, 2013 May.
Artículo en Inglés | MEDLINE | ID: mdl-23558840

RESUMEN

BACKGROUND: The pattern and magnitude of the hyperglycemic response to surgical stress, the added effect of low-dose steroids, and whether these differ in diabetics and nondiabetics remain unclear. We therefore tested 2 hypotheses: (1) that diabetics show a greater increase from preoperative to intraoperative glucose concentrations than nondiabetics; and (2) that steroid administration increases intraoperative hyperglycemia more so in diabetics compared with nondiabetics. METHODS: Patients scheduled for major noncardiac surgery under general anesthesia were enrolled and randomized to preoperative IV 8 mg dexamethasone or placebo, stratified by diagnosis of diabetes. Patients were part of a larger underlying trial (the Dexamethasone, Light Anesthesia and Tight Glucose Control [DeLiT] Trial). IV insulin was given when glucose concentration exceeded 215 mg/dL. The primary outcome measure was the change in glucose from the preoperative to maximal intraoperative glucose concentration. We also report the time-dependent pattern of intraoperative hyperglycemia. RESULTS: Ninety patients (23% with diabetes) were randomized to dexamethasone, and 95 (29% with diabetes) were given placebo. The mean ± SD change from preoperative to maximal intraoperative glucose concentration was 63 ± 69 mg/dL in diabetics and 72 ± 45 mg/dL in nondiabetics. The mean covariable-adjusted change (95% confidence interval) in nondiabetics was 29 (13, 46) mg/dL more than in diabetics (P < 0.001). For all patients combined, mean glucose increased slightly from preoperative to incision, substantially from incision to surgery midpoint, and then remained high and fairly stable through emergence, with nondiabetic patients showing a greater increase (P < 0.001). For nondiabetics, the mean increase in glucose concentration (97.5% CI) was 29 (9, 49) mg/dL more in patients given dexamethasone than placebo (P = 0.0012). However, there was no dexamethasone effect in diabetics (P = 0.99). CONCLUSIONS: Treatment of intraoperative hyperglycemia should account for the hyperglycemic surgical stress response trend depending on the stage of surgery as well as the added effects of steroid administration. Denying steroid prophylaxis for postoperative nausea and vomiting for fear of hyperglycemic response should be reconsidered given the limited effect of steroids on intraoperative blood glucose concentrations.


Asunto(s)
Antieméticos/efectos adversos , Diabetes Mellitus/sangre , Hiperglucemia/etiología , Esteroides/efectos adversos , Procedimientos Quirúrgicos Operativos/efectos adversos , Anciano , Anestesia General , Glucemia/metabolismo , Dexametasona/efectos adversos , Método Doble Ciego , Femenino , Humanos , Hiperglucemia/sangre , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Náusea y Vómito Posoperatorios/prevención & control
14.
Anesth Analg ; 125(2): 369-371, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28731970
15.
Chest ; 161(4): 1112-1121, 2022 04.
Artículo en Inglés | MEDLINE | ID: mdl-34774820

RESUMEN

Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards, and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from preoperative care to discharge/disposition, are highlighted. The importance of effective business planning, personnel training, leadership, communication, team building, quality of care, and patient safety are also discussed.


Asunto(s)
Anestesiología , Broncoscopía , Centros Médicos Académicos , Broncoscopía/métodos , Humanos , Liderazgo , Seguridad del Paciente
17.
F1000Res ; 92020.
Artículo en Inglés | MEDLINE | ID: mdl-32489647

RESUMEN

Clinical airway management continues to advance at a fast pace. To help update busy anesthesiologists, this abbreviated review summarizes notable airway management advances over the past few years. We briefly discuss advances in video laryngoscopy, in flexible intubation scopes, in jet ventilation, and in extracorporeal membrane oxygenation (ECMO). We also discuss noninvasive ventilation in the forms of high-flow nasal cannula apneic oxygenation and ventilation and nasal continuous positive airway pressure (CPAP) masks. Emerging concepts related to airway management, including the physiologically difficult airway and lower airway management, new clinical subspecialties and related professional organizations such as Anesthesia for Bronchoscopy, the Society for Head and Neck Anesthesia, and fellowship training programs related to advanced airway management are also reviewed. Finally, we discuss the use of checklists and guidelines to enhance patient safety and the value of large databases in airway management research.


Asunto(s)
Manejo de la Vía Aérea , Broncoscopía , Cánula , Humanos , Respiración Artificial
18.
Cleve Clin J Med ; 2020 Aug 05.
Artículo en Inglés | MEDLINE | ID: mdl-32759174

RESUMEN

Bronchoscopy is an aerosol-generating procedure that creates unique challenges for healthcare providers to reduce the potential spread of the COVID-19 respiratory pathogen. As part of the initial response, Cleveland Clinic postponed elective surgeries including bronchoscopy. We established a 5-tier system for prioritizing the urgency of bronchoscopy procedures. When elective bronchoscopies were resumed, we established protocols to reduce aerosolization and potential virus transmission risks such as using an airborne infection-isolation room and changing to total intravenous anesthesia. Also, we established guidelines for periprocedural care and use of personal protective equipment including requirements for wearing N95 masks for all bronchoscopy procedures.

19.
Otolaryngol Clin North Am ; 52(6): 1049-1063, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31563422

RESUMEN

Via the emergence of new bronchoscopic technologies and techniques, there is enormous growth in the number of procedures being performed in nonoperating room settings. This, coupled with a greater focus from the Centers for Medicare and Medicaid Services for mandated anesthesiology oversight of procedural sedation for bronchoscopy by the pulmonologists has led to a more frequent working partnership between interventional pulmonologists and anesthesiologists. This article offers the interventional pulmonologist insight into how the anesthesiologist thinks and approaches anesthetic care delivery.


Asunto(s)
Anestesia/métodos , Broncoscopía/métodos , Comunicación Interdisciplinaria , Anestesiólogos , Humanos , Neumólogos
20.
J Clin Anesth ; 55: 83-91, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30599425

RESUMEN

STUDY OBJECTIVES: The postoperative period is associated with an inflammatory response that may contribute to a number of complications including postoperative fatigue (POF) that impair patients' quality of life (QoL). We studied the impact of three potentially anti-inflammatory interventions (steroid administration, tight intraoperative glucose control, and light anesthesia) on POF and QoL in patients having major noncardiac surgery. DESIGN: A randomized Trial. SETTING: Operating room and postoperative recovery area/ICU/hospital floors. PATIENTS: Patients undergoing major noncardiac surgery. INTERVENTIONS: Patients were randomized to perioperative IV dexamethasone (a total of 14 mg tapered over 3 days) versus placebo, intensive versus conventional glucose control (target 80-110 vs. 180-200 mg·dL-1), and light versus deep anesthesia (Bispectral Index target of 55 vs. 35) in a 3-way factorial design. MEASUREMENTS: In this planned sub-analysis, QoL was measured using SF-12 preoperatively and on postoperative day (POD) 30. POF was measured using Christensen VAS, pre-operatively, POD 1, and POD 3. We assessed the effect of each intervention on POF and on the physical and mental components of SF-12 summary scores with repeated-measures linear regression models. MAIN RESULTS: 326 patients with complete data were included in the SF-12 analysis and 306 were included in the QoL analysis. No difference was found between any of the intervention groups on fatigue or mean 30-day physical and mental components of SF-12 scores, after adjusting for preoperative score and imbalanced baseline variables (all P-value >0.07 for POF and >0.40 for QoL). CONCLUSIONS: Steroid administration, tight intraoperative glucose control, and light anesthesia do not improve quality of life or postoperative fatigue after major surgery.


Asunto(s)
Anestesia General/métodos , Glucemia/análisis , Dexametasona/administración & dosificación , Fatiga/prevención & control , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Operativos/efectos adversos , Anciano , Anestesia General/efectos adversos , Glucemia/efectos de los fármacos , Método Doble Ciego , Fatiga/sangre , Fatiga/etiología , Femenino , Humanos , Hipoglucemiantes/administración & dosificación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Calidad de Vida , Resultado del Tratamiento
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