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1.
Br J Anaesth ; 124(1): 73-83, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860444

RESUMO

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.


Assuntos
Serviços Médicos de Emergência , Laparotomia/mortalidade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores Socioeconômicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Inglaterra/epidemiologia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/normas , Pobreza , Risco Ajustado , Medicina Estatal , Adulto Jovem
2.
Br J Anaesth ; 123(5): 664-670, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31493848

RESUMO

BACKGROUND: Patient-centred outcomes are increasingly used in perioperative clinical trials. The Standardised Endpoints in Perioperative Medicine (StEP) initiative aims to define which measures should be used in future research to facilitate comparison between studies and to enable robust evidence synthesis. METHODS: A systematic review was conducted to create a longlist of patient satisfaction, health-related quality of life, functional status, patient well-being, and life-impact measures for consideration. A three-stage Delphi consensus process involving 89 international experts was then conducted in order to refine this list into a set of recommendations. RESULTS: The literature review yielded six patient-satisfaction measures, seven generic health-related quality-of-life measures, eight patient well-being measures, five functional-status measures, and five life-impact measures for consideration. The Delphi response rates were 92%, 87%, and 100% for Rounds 1, 2, and 3, respectively. Three additional measures were added during the Delphi process as a result of contributions from the StEP group members. Firm recommendations have been made about one health-related quality-of-life measure (EuroQol 5 Dimension, five-level version with visual analogue scale), one functional-status measure (WHO Disability Assessment Schedule version 2.0, 12-question version), and one life-impact measure (days alive and out of hospital at 30 days after surgery). Recommendations with caveats have been made about the Bauer patient-satisfaction measure and two life-impact measures (days alive and out of hospital at 1 yr after surgery, and discharge destination). CONCLUSIONS: Several patient-centred outcome measures have been recommended for use in future perioperative studies. We suggest that every clinical study should consider using at least one patient-centred outcome within a suite of endpoints.


Assuntos
Determinação de Ponto Final/normas , Avaliação de Resultados da Assistência ao Paciente , Assistência Perioperatória/normas , Atividades Cotidianas , Técnica Delfos , Humanos , Satisfação do Paciente , Assistência Perioperatória/métodos , Psicometria , Qualidade de Vida , Procedimentos Cirúrgicos Operatórios/reabilitação
5.
Zhonghua Wai Ke Za Zhi ; 57(7): 513-516, 2019 Jul 01.
Artigo em Chinês | MEDLINE | ID: mdl-31269613

RESUMO

As the concept of enhanced recovery after surgery (ERAS) have been widely promoted and applied in clinical practice,reasonable nutrition intervention strategy has been paid more and more attention. The whole-process nutrition management strategy has been optimized based on the ERAS concept,which mainly includes key points such as pre-operative nutrition screening and nutrition assessment,perioperative nutrition treatment,and post-discharge nutritional support. With more and more research evidences,the ERAS strategy would be more detailed and complete. Further nutrition-related high-quality researches is necessary to provide evidence support,aiming to establish a standardized,ERAS-optimized,whole-process nutrition management pathway.


Assuntos
Protocolos Clínicos/normas , Terapia Nutricional/normas , Assistência Perioperatória/normas , Humanos , Avaliação Nutricional , Estado Nutricional , Apoio Nutricional , Cuidados Pré-Operatórios
8.
Khirurgiia (Mosk) ; (7): 58-62, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31355816

RESUMO

OBJECTIVE: To assess standardized protocol for fast track recovery after lung cancer surgery. MATERIAL AND METHODS: There were 201 patients. Patients underwent VATS lung resection, VATS lobectomy and various open resections of lungs. Patients had either primary lung cancer or metastatic lung lesion with indications for surgical treatment. Management of patients was divided into 3 periods: preoperative, intraoperative and postoperative. The protocol of fast track recovery was developed considering literature data and own experience. Requirements of this protocol were applied in perioperative management. RESULTS: Application of the protocol was successful in all patients. Minimum number of complications (6%) and length of postoperative hospital-stay of 4 days were observed after VATS resection of lung. VATS lobectomy was followed by complication rate 25% and postoperative hospital-stay of 6 days. In the group of open resections these values were 29% and 7 days.


Assuntos
Protocolos Clínicos/normas , Neoplasias Pulmonares/cirurgia , Assistência Perioperatória/normas , Pneumonectomia , Cuidados Pré-Operatórios/normas , Humanos , Tempo de Internação , Pneumonectomia/métodos , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida
9.
Spine (Phila Pa 1976) ; 44(13): 959-966, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31205177

RESUMO

STUDY DESIGN: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE: 3.


Assuntos
Procedimentos Neurocirúrgicos/normas , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/métodos , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Satisfação do Paciente , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Melhoria de Qualidade/normas , Resultado do Tratamento
10.
Br J Anaesth ; 123(2): 228-237, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31128879

RESUMO

BACKGROUND: Clinical indicators are powerful tools to quantify the safety and quality of patient care. Their validity is often unclear and definitions extremely heterogeneous. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid clinical outcome indicators for use in perioperative clinical trials. METHODS: We identified clinical indicators via a systematic review of the anaesthesia and perioperative medicine literature (PubMed/OVID, EMBASE, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 54 clinician-researchers worldwide. Indicators were first shortlisted and the most suitable definitions for evaluation of quality and safety interventions determined. Indicators were then assessed for validity, reliability, feasibility, and clarity. RESULTS: We identified 167 clinical outcome indicators. Participation in the three Delphi rounds was 100% (n=13), 68% (n=54), and 85% (n= 6), respectively. A final list of eight outcome indicators was generated: surgical site infection at 30 days, stroke within 30 days of surgery, death within 30 days of coronary artery bypass grafting, death within 30 days of surgery, admission to the intensive care unit within 14 days of surgery, readmission to hospital within 30 days of surgery, and length of hospital stay (with or without in-hospital mortality). They were rated by the majority of experts as valid, reliable, easy to use, and clearly defined. CONCLUSIONS: These clinical indicators can be confidently used as endpoints in clinical trials measuring quality, safety, and improvement in perioperative care. REGISTRATION: PROSPERO 2016 CRD42016042102 (http://www.crd.york.ac.uk/PROSPERO/display_record.php? ID=CRD42016042102).


Assuntos
Consenso , Segurança do Paciente/normas , Assistência Perioperatória/normas , Qualidade da Assistência à Saúde/normas , Ensaios Clínicos como Assunto , Humanos , Padrões de Referência , Reprodutibilidade dos Testes
11.
Curr Opin Anaesthesiol ; 32(3): 392-397, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045641

RESUMO

PURPOSE OF REVIEW: To review the developments within paediatric anaesthesia and describe the various factors that have contributed to the improvements in anaesthesia-related outcomes in children. RECENT FINDINGS: During the years substantial improvements in paediatric anaesthesia-related outcomes has derived from safety advances in equipment, drugs, human factor analysis, professional standardization and organization, subspecialty care and regionalization. However, universally agreed outcome measures are lacking. SUMMARY: Despite a steadily and significant improvement in paediatric anaesthesia-related outcomes over the years further and future improvements are still necessary in areas such as adverse-event reporting and long-term neurocognitive outcomes with much more focus on patient/family-centred outcomes. Clinical experts and stakeholders should meet and agree on a consensus to identify indicators that could act as outcome measures in future large-scale prospective observational studies and clinical trials. Such an approach will foster benchmarking and continuous quality assessment and improvement at individual, institutional, interinstitutional, regional, national and international levels and facilitate larger scale clinical research. Furthermore, it will attain a high public health importance and will facilitate comparisons between healthcare provision models leading to optimization of perioperative care delivery.


Assuntos
Anestesia/métodos , Assistência Perioperatória/métodos , Anestesia/efeitos adversos , Anestesia/normas , Benchmarking/organização & administração , Criança , Ensaios Clínicos como Assunto , Humanos , Estudos Observacionais como Assunto , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/normas , Melhoria de Qualidade/organização & administração
12.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(4): 301-314, 2019 Apr 25.
Artigo em Chinês | MEDLINE | ID: mdl-31054543

RESUMO

Surgical site infection (SSI) is one of the most common health care-associated infections, which increases patients' financial burden, prolongs hospital days, and even raises mortality. Prevention of SSI requires the integration of a range of preventive measures before, during, and after surgery. This guideline is based on current evidence and clinical practice, and takes into account the balance between benefits and harms, the evidence quality level, cost and resource allocation, and patient values and preferences. We present in this guideline 22 recommendations suitable for Chinese conditions and specific to the preoperative, intraoperative and postoperative periods. Preventive measures including nutritional support, immunosuppressive agents, bathing, mechanical bowel preparation with oral antibiotics, hair removal, optimal timing for administration of surgical antibiotic prophylaxis, and surgical hand preparation, were involved in the preoperative period. During the intraoperative and postoperative period, preventive measures include normothermia, blood glucose control, fluid therapy, drapes and gowns, wound-protector devices, incisional wound irrigations, prophylactic vacuum suction therapy, antimicrobial-coated sutures, antimicrobial prophylaxis in the presence of a drainage, optimal timing for wound drain removal, wound dressing, and surgical antibiotic prophylaxis prolongation. It should be noted that when applying recommendations, surgeons should combine the conditions of their hospitals and patients' conditions. More researches are required to further investigate unsolved problems.


Assuntos
Infecção Hospitalar/prevenção & controle , Assistência Perioperatória/normas , Guias de Prática Clínica como Assunto/normas , Infecção da Ferida Cirúrgica/prevenção & controle , China , Humanos
13.
J Nurses Prof Dev ; 35(4): E9-E14, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31135616

RESUMO

The obstetrical unit utilized a training product (Periop 101: A Core Curriculum OB) to enhance the knowledge, self-efficacy, and performance of nurses circulating for cesarean births. Knowledge was measured using product provided testing. Self-efficacy was assessed using a modified perioperative self-efficacy scale, and performance was evaluated by analyzing documentation accuracy and incident reports. Results demonstrated improvements in perioperative knowledge, self-efficacy, and documentation as well as a reduction in incident reports.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Enfermagem Obstétrica/educação , Assistência Perioperatória/normas , Melhoria de Qualidade , Autoeficácia , Adulto , Competência Clínica/normas , Currículo , Educação Continuada em Enfermagem , Avaliação Educacional/estatística & dados numéricos , Feminino , Humanos , Masculino , Gravidez
14.
Medicine (Baltimore) ; 98(20): e15424, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096438

RESUMO

BACKGROUND: The aim of this systematic review and meta-analysis is to comprehensively evaluate the efficacy and safety of the perioperative use of sunitinib in patients with metastatic and advanced renal cell carcinoma (RCC). MATERIALS AND METHODS: We searched authenticated databases for related clinical studies. The baseline characteristics, parameters concerning the efficacy and safety of the perioperative use of sunitinib were extracted for subsequent comprehensive analysis. The parameters which reflected the efficacy and safety as overall survival (OS), progression-free survival (PFS), occurrence rate of all-grade and grade ≥3 adverse effects (AEs) were carefully pooled using comprehensive meta-analysis. RESULTS: We finally recruited 411 patients from 14 eligible studies. We found proteinuria (75.0%, 95% CI 62.1%-84.6%), anemia (71.6%, 95% CI 60.9%-80.3%), athesia (60.0%, 95% CI 40.3%-77.0%), pause symptoms (59.2%, 95% CI 49.2%-68.4%), arterial hypertension (53.1%, 95% CI 43.2%-62.7%), and thrombocytopenia (52.5%, 95% CI 44.8%-60.0%) to be the most common all-grade AEs. And arterial hypertension, athesia, cutaneous toxicity, hypophosphatemia, leukopenia, pain, pause syndrome, renal dysfunction, and thrombocytopenia were the most common types of grade ≥3 AEs. In addition, objective response rate (ORR) of sunitinib to both the original and metastatic tumor sites increased with the use of sunitinib, so did the OS and PFS. CONCLUSION: Common all-grade and grade ≥3 AEs were carefully monitored. The perioperative use of sunitinib showed superior ORR, OS, and PFS rates. Nevertheless, more studies are required to further verify these findings.


Assuntos
Carcinoma de Células Renais/tratamento farmacológico , Assistência Perioperatória/normas , Sunitinibe/efeitos adversos , Sunitinibe/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/induzido quimicamente , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/secundário , Intervalo Livre de Doença , Feminino , Humanos , Hipertensão/induzido quimicamente , Neoplasias Renais/tratamento farmacológico , Neoplasias Renais/patologia , Neoplasias Renais/secundário , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Inibidores de Proteínas Quinases/administração & dosagem , Inibidores de Proteínas Quinases/efeitos adversos , Inibidores de Proteínas Quinases/uso terapêutico , Proteinúria/induzido quimicamente , Sunitinibe/administração & dosagem , Trombocitopenia/induzido quimicamente
15.
Curr Opin Anaesthesiol ; 32(3): 421-426, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31048597

RESUMO

PURPOSE OF REVIEW: Hypertension is a leading disease in preoperative clinics; nearly 60% of patients over 60 years have it. Many guidelines have been published for the diagnosis and treatment of hypertension. Last year, the American College of Cardiology/American Heart Association and European Society of Cardiology and European Society of Hypertension made new recommendations for diagnosis and management, with special emphasis on targets, nonpharmacological treatment, and management of the elderly patient, and pharmacological therapy. We will review relevant concordances and differences that are important for the anesthesiologist and perioperative management. RECENT FINDINGS: Adults with stage 1 hypertension have a two-fold increase in cardiovascular disease risk. Tight blood pressure management improves outcome. Discontinuing angiotensin receptor blockers/angiotensin converting enzyme inhibitors is associated with less intraoperative hypotension and probably less morbidity and mortality. SUMMARY: New guidelines could increase the burden of patients with pharmacological treatment that will need surgery and require case by case considerations. The scarcity of information demands trials about blood pressure management and consensus about antihypertensive medications in perioperative period.


Assuntos
Anti-Hipertensivos/administração & dosagem , Hipertensão/complicações , Assistência Perioperatória/normas , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/normas , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Guias de Prática Clínica como Assunto , Sociedades Médicas/normas
16.
Curr Opin Anaesthesiol ; 32(3): 398-404, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30958402

RESUMO

PURPOSE OF REVIEW: The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed. RECENT FINDINGS: The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes. SUMMARY: Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.


Assuntos
Diabetes Mellitus/tratamento farmacológico , Hipoglicemiantes/administração & dosagem , Insulina/administração & dosagem , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Administração Oral , Glicemia/análise , Glicemia/efeitos dos fármacos , Glicemia/fisiologia , Diabetes Mellitus/sangue , Humanos , Hipoglicemiantes/efeitos adversos , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Assistência Perioperatória/normas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Operatórios/efeitos adversos
17.
Holist Nurs Pract ; 33(3): 163-176, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30973436

RESUMO

Postoperative delirium (incidence estimated up to 82%) can be ameliorated with nonpharmacologic methods. Mindfulness has not yet been incorporated into these methods, although mindfulness has been demonstrated to help patients adapt to illness and hospitalization. To reduce postoperative delirium incidence and increase patient satisfaction, this study employs a program of thought exercises based on Langerian mindfulness. Preoperatively, cardiac surgical patients listened to a mindfulness or informational audio; mindfulness subjects were also guided by the principal investigator through mindfulness exercises. Postoperatively, mindfulness subjects were visited twice daily for mindfulness exercises. For all patients, delirium screening was performed twice daily. Before discharge, affective status and satisfaction with hospital stay were assessed. No patients who completed the study screened positive for delirium. Trends include (1) lower (improved) median anxiety and depression scores postoperatively when considering both study groups together; (2) both groups rated the hospital more favorably on global satisfaction measures; (3) both groups shared generally positive comments regarding the audio files (qualitative data). Audio files and mindfulness exercises are associated with patient satisfaction among cardiothoracic surgery patients. The absence of delirium precludes determination of the effectiveness of the intervention in reducing delirium incidence.


Assuntos
Delírio/prevenção & controle , Atenção Plena/métodos , Atenção Plena/normas , Satisfação do Paciente , Adulto , Idoso , Delírio/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Projetos Piloto , Inquéritos e Questionários
18.
Mo Med ; 116(1): 53-57, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30862987

RESUMO

The practice of Perioperative Medicine is in need of greater coordination and organization. The traditional model of perioperative patient care, scheduling surgical care based primarily on surgeon/patient availability, along with the operative need, with little thought for coordination and planning to ensure that patients can safely undergo surgery and expect the best possible outcome, is in need of a paradigm change. Return to the highest level of functionality should be the patient centered approach.


Assuntos
Assistência à Saúde/normas , Assistência Centrada no Paciente/normas , Assistência Perioperatória/normas , Melhoria de Qualidade , Humanos , Segurança do Paciente/normas , Assistência Centrada no Paciente/organização & administração
19.
Br J Anaesth ; 122(4): 500-508, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30857606

RESUMO

BACKGROUND: Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. METHODS: We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures. RESULTS: A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use. CONCLUSIONS: We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.


Assuntos
Determinação de Ponto Final/normas , Assistência Perioperatória/normas , Técnica Delfos , Humanos , Infecções Respiratórias/terapia , Sepse/terapia , Infecção da Ferida Cirúrgica/terapia
20.
Curr Opin Anaesthesiol ; 32(3): 343-352, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30893114

RESUMO

PURPOSE OF REVIEW: Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered. RECENT FINDINGS: Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols. SUMMARY: Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.


Assuntos
Antifibrinolíticos/administração & dosagem , Perda Sanguínea Cirúrgica/prevenção & controle , Assistência Perioperatória/métodos , Hemorragia Pós-Operatória/terapia , Ácido Tranexâmico/administração & dosagem , Antifibrinolíticos/efeitos adversos , Transfusão de Sangue/estatística & dados numéricos , Criança , Relação Dose-Resposta a Droga , Humanos , Infusões Intravenosas , Assistência Perioperatória/normas , Hemorragia Pós-Operatória/etiologia , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Ácido Tranexâmico/efeitos adversos , Reação Transfusional/prevenção & controle , Resultado do Tratamento
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