Pharmacogenomics, concepts for the future of perioperative medicine and pain management: A review.

Pharmacogenomics is the study of how genetic differences between individuals affect pharmacokinetics and pharmacodynamics. These differences are apparent to clinicians when taking into account the wide range of responses to medications given in clinical practice. A review of literature involving pharmacogenomics and pain management was performed. The implementation of preoperative pharmacogenomics will allow us to better care for our patients by delivering personalized, safer medicine. This review describes the current state of pharmacogenomics as it relates to many aspects of clinical practice and how clinicians can use these tools to improve patient outcomes.

Science Without Conscience Is but the Ruin of the Soul: The Ethics of Big Data and Artificial Intelligence in Perioperative Medicine.

Artificial intelligence-driven anesthesiology and perioperative care may just be around the corner. However, its promises of improved safety and patient outcomes can only become a reality if we take the time to examine its technical, ethical, and moral implications. The aim of perioperative medicine is to diagnose, treat, and prevent disease. As we introduce new interventions or devices, we must take care to do so with a conscience, keeping patient care as the main objective, and understanding that humanism is a core component of our practice. In our article, we outline key principles of artificial intelligence for the perioperative physician and explore limitations and ethical challenges in the field.

Factors Affecting the Thermal Comfort of Perioperative Personnel in the OR.

Thermal comfort is an important component of any work setting and can be difficult to achieve in the complex OR environment. This comparative descriptive study sought to identify factors affecting the thermal comfort of perioperative personnel in the OR (N = 68). Researchers used the American Society of Heating, Refrigerating and Air-Conditioning Engineers Thermal Sensation Scale and researcher-developed surveys to collect data. The mean reported thermal comfort level was -0.44 (standard deviation 1.3), which is within acceptable parameters. Factors affecting thermal comfort were gender, professional role, and wearing additional clothing. Additionally, participants who complained about temperature or ventilation were less likely to report thermal comfort levels in the normal range. Health care facility leaders should consider the comfort needs of perioperative personnel when making purchasing decisions about ventilation systems and surgical clothing; however, they also should consider other factors (eg, surgeon comfort, permeability of protective clothing to blood and other body fluids).

Immunomodulatory effects of anesthetic agents in perioperative medicine.

Anesthetics comprise a heterogeneous group of drugs with multiple functions and mechanisms of action, which are not yet fully elucidated. In the clinical setting, it is difficult to isolate the effects of anesthetic agents from those of surgical stress itself or of other individual covariates. For this reason, several methods involving human immune cells and animal models have been used to study the effects of anesthetic agents on the immune system. The immunomodulation caused by anesthetic agents may lead to distinct consequences: suppression of the immune response, preventing or minimizing further distal organ injury; or suppression of the host immune reaction, which can lead to unacceptably increased risk of opportunistic infections. This review discusses the perioperative inflammatory response and the immunomodulatory properties of the most commonly used anesthetic agents in the perioperative period, addressing both their effects and proposed mechanisms of action on the innate immune system, including: biochemical and cellular defenses; barriers such as the endothelium and epithelium; biological macromolecules; domain proteins; specific cell types; and molecules such as cytokines and chemokines, which coordinate the host defense process. The immunomodulatory consequences of general anesthesia are complex. Immunosuppression can lead to beneficial effects, reducing systemic and local inflammation, or negative effects, which result in increased risk of infection. Anesthesiologists should choose the most appropriate agents based on the immune status of each patient.

Levosimendan in the light of the results of the recent randomized controlled trials: an expert opinion paper.

Despite interesting and unique pharmacological properties, levosimendan has not proven a clear superiority to placebo in the patient populations that have been enrolled in the various recent multicenter randomized controlled trials. However, the pharmacodynamic effects of levosimendan are still considered potentially very useful in a number of specific situations.Patients with decompensated heart failure requiring inotropic support and receiving beta-blockers represent the most widely accepted indication. Repeated infusions of levosimendan are increasingly used to facilitate weaning from dobutamine and avoid prolonged hospitalizations in patients with end-stage heart failure, awaiting heart transplantation or left ventricular assist device implantation. New trials are under way to confirm or refute the potential usefulness of levosimendan to facilitate weaning from veno-arterial ECMO, to treat cardiogenic shock due to left or right ventricular failure because the current evidence is mostly retrospective and requires confirmation with better-designed studies. Takotsubo syndrome may represent an ideal target for this non-adrenergic inotrope, but this statement also relies on expert opinion. There is no benefit from levosimendan in patients with septic shock. The two large trials evaluating the prophylactic administration of levosimendan (pharmacological preconditioning) in cardiac surgical patients with poor left ventricular ejection fraction could not show a significant reduction in their composite endpoints reflecting low cardiac output syndrome with respect to placebo. However, the subgroup of those who underwent isolated CABG appeared to have a reduction in mortality. A new study will be required to confirm this exploratory finding.Levosimendan remains a potentially useful inodilator agent in a number of specific situations due to its unique pharmacological properties. More studies are needed to provide a higher level of proof regarding these indications.

Road to Perioperative Medicine: A Perspective From China.

With the development of anesthesiology, patient safety has been remarkably improved, but the postoperative mortality rate at 30 days is still as high as 0.56%-4%, and the morbidity is even higher. Three years ago, the Chinese Society of Anesthesiology proposed that the direction of the anesthesiology development should be changed to perioperative medicine in China. Anesthesiologists should pay more attention to the long-term outcome. In this article, we introduced what we have done, what the challenges are, and what we should do in the future with regard to the practice of perioperative medicine in China.

Medicina perioperatoria ¿El futuro de la anestesiología? / Perioperative Medicine, the Future of Anesthesiology?

We are in the middle of great changes in health care worldwide. There is great pressure to contain costs, population ages rapidly and at the same time significant technological advances are continuously incorporated into medical practice. In the near future, it is likely that reimbursement and incentive mechanisms will also change, and progress will be made towards what has been called value-based medical care, where compensation will be directly related to clinical outcomes. Anesthesiology as a specialty, needs also to adapt to these new scenarios, given that the perioperative period as a whole have been observed as not very efficient and susceptible to improvement. This is why, in many places, anesthesiologists, given their wide range of clinical skills, are beginning to expand their field of action towards clinical activities outside the operating room, taking care of the patient through all their surgical process, which has been called Perioperative Medicine. The anesthesiologist is evolving towards this new type of specialist and this is how they effectively add value to medical care as a whole.

Estamos en medio de una etapa de grandes cambios en atención de salud en todo el mundo. Existe gran presión por contener los costos, envejece la población y al mismo tiempo se incorporan rápidamente adelantos tecnológicos a nuestra práctica médica. Muy probablemente, en el futuro cercano cambien también los mecanismos de pago e incentivos y se avance a lo que se ha denominado atención médica basada en el valor, donde las compensaciones estarán directamente relacionadas con los desenlaces o resultados. La anestesiología como especialidad, también deberá adaptarse a estos nuevos escenarios, dado que el período perioperatorio en su conjunto ha sido observado como poco eficiente y susceptible de mejorar. Es aquí donde en muchos lugares los anestesiólogos, dado su amplia gama de competencias clínicas, están empezando a aumentar su campo de acción hacia actividades clínicas fuera del pabellón, haciéndose cargo del paciente a través de todo su proceso quirúrgico lo que se ha denominado Medicina Perioperatoria. El anestesiólogo está evolucionando hacia este nuevo tipo de especialista y es de esta manera como efectivamente logra agregar valor al cuidado médico en su conjunto.