Current Anesthesiology Reports

The purpose of this review was to provide an overview of the recent concepts regarding cardiac output measurement devices that utilize non-pulse contour methods, especially in an intraoperative setting. The techniques include inert gas rebreathing method, partial CO2 rebreathing method, impedance cardiography, and its derivative technologies such as electrical velocimetry and bioreactance, transesophageal echocardiography/Doppler, and transthoracic echocardiography/Doppler. We focused on the invasiveness of the devices and their underlying technology. Although various types of cardiac output monitoring devices are available, none of them may be considered as an ideal device in terms of accuracy, trending ability of cardiac output changes, and reproducibility of measurements. There are increasing types of devices applicable for intraoperative use, yet only few data are available regarding the trending ability of cardiac output changes and reproducibility of the measurements. Therefore, the empirical application of these devices for various surgical patients may be done under the consideration of their invasiveness and their underlying technology, and it may provide us with more data over time. The non-pulse contour-derived cardiac output measurement devices are classified according to their underlying principles, which closely reflect their advantages and disadvantages in the perioperative setting.

This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury. Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described. Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.

This article focuses on the following: Practical tips and suggestions are shared by the authors to assist others when implementing prehabilitation programmes. These include experience from three different approaches with similar lessons. Important elements include the following: (i) starting with a small identified clinical group of patients to refine and test the delivery model and demonstrate proof of concept; (ii) systematic data collection with clearly identified target outcomes from the outset; (iii) collaboration with a wide range of stakeholders including those who will be designing, developing, delivering, funding and using the prehabilitation services; (iv) adapting the model to fit local situations; (v) project leaders who can bring together and motivate a team; (vi) recognition and acknowledgement of the value that each member of a diverse multidisciplinary team brings; (vii) involvement of the whole team in prehabilitation prescription including identification of patients’ levels of risk through appropriate assessment and need-based interventions; (viii) persistence and determination in the development of the business case for sustainable funding; (ix) working with patients ambassadors to develop and advocate for the case for support; and (x) working closely with commissioners of healthcare. Principles for the implementation of prehabilitation have been set out by sharing the experiences across three countries. These principles should be considered a framework for those wishing to design and develop prehabilitation services in their own areas to maximise success, effectiveness and sustainability.

Non-operating room anesthesia (NORA) has continued to grow. This review provides recent views on the subject and an overview of specific concerns in specialized NORA applications. Recent literature has reviewed the data from national databases and found no differences in the outcomes of patients undergoing NORA for procedural interventions as opposed to those patients undergoing surgical procedures. Specific areas may have their own challenges and types of patients; however, creation of a system for evaluating, anesthetizing, and recovering these patient from anesthesia results in significant patient benefit. NORA has been shown to be safe in recent reviews of national data. The future will most likely involve increasing use of NORA; thus, involvement of anesthesiology departments in the planning and building of new spaces for interventions will augment the benefit and decrease the risk of future patient care.

Prompt attention to airway management is a fundamental component of the approach to trauma anesthesiology. While anesthesiologists manage the greatest number of airways in their training and practice, a variety of medical providers perform airway management in the trauma population (i.e., paramedics, emergency physicians, anesthesiologists, respiratory therapists). Rates of successful intubation can vary widely between groups; therefore, a definition of expertise is required to develop training plans, as well as standards for maintenance of proficiency. While competency is challenging to define in any field, the data suggest that individuals with the greatest experience achieve the highest level of success. Given that anesthesiologists manage several thousand airway encounters throughout their training and careers, their leadership as subject matter experts is essential to development of training curricula in airway management of all varieties. Consensus on training of less experienced providers, as well as tasking of the most difficult cases to the most experienced provider, is imperative for successful airway management in trauma.

Since their introduction almost a century ago, intensive care units have become an essential part of the health care system. Although the majority are found in the high-income countries, access to intensive care in the low-income countries has improved. The purpose of this review is to report on the current state of intensive care in resource-limited settings. Lack of basic health care resources still poses a specific challenge to the development and sustainability of health care. In addition, adequate funding, human resource training, and equipment specific to the specialty of critical care pose an even larger setback to the development of critical care in low-resource-limited settings. Deaths potentially preventable with access to critical care as presented by data from the global disease burden analysis in 2004 are approximately 70% of all recorded deaths in low-income countries. This reflects the large burden of critical illness in low-income countries. Efforts to increase access to hospitals and intensive care for all critically ill patients should grow to match these needs.

Sedation and anesthesia in dental office–based settings are specialty practices that have unfortunately been riddled with bad outcomes and near misses. Both healthcare professionals and the public usually receive information about these events from media reports and seldom from any other comprehensive sources. This review will identify potential sources of reliable data in which to guide practice and training. Recent investigations into the training of practitioners and auxiliaries, the dental office–based setting, and regulations governing dental sedation and dental anesthesia practice have highlighted a glaring lack of reliable data in which to pinpoint root causes and potential solutions. The path forward to increased safety may exist in awareness of the issues and potential closed-claims analysis of outcomes. Because of the lack of systemic and ongoing data collection for mainly private practice and dental office–based sedation and anesthesia settings, insurance and closed-claims data investigations may be the most reliable source for current morbidity and mortality examinations.

This chapter will highlight several important concepts that are relevant to the assessment and optimization of hospitalized patients prior to the administration of an anesthetic. Patients admitted to hospital comprise a unique population. The risk-benefit ratio of pre-procedural investigations and the economic implications of specific management strategies may be significantly different than for patients managed on an ambulatory basis. The anesthesiologist must have a thorough understanding of these factors. Preoperative workflows provide effective coordination of the necessary resources and ensure that each patient’s procedure is completed as safely and efficiently as possible. A working knowledge of reimbursement principles, expertise in local procedural workflows, and the ability to quickly and effectively screen patients for high-risk conditions place anesthesiologists at the center of the perioperative process and the financial viability of their inpatient facility.