The prophylaxis and treatment of postoperative pain to enhance patient comfort has been a primary goal of anesthesiologists for the last decades; however, avoiding postoperative nausea and vomiting (PONV) is, from a patient\'s perspective, a highly relevant and equally important goal of anesthesia. Recent consensus-based guidelines suggest the assessment of risk factors including female gender, postoperative opioid administration, non-smoking status, a history of PONV or motion sickness, young patient age, longer duration of anesthesia, volatile anesthetics and the type of surgery and reducing the patient\'s baseline risk (e.g. through the use of regional anesthesia and administration of non-opioid analgesics as part of a multimodal approach). In general, a liberal PONV prophylaxis is encouraged for adult patients and children, which should also be administered when no risk assessment is made. The basis for every adult patient should be a standard prophylaxis with two antiemetics, such as dexamethasone in combination with a 5-HT3 receptor antagonist. In patients at high risk, this should be supplemented by a third and potentially a fourth antiemetic prophylaxis with a different mechanism of action. A recently published comprehensive Cochrane meta-analysis comparing available antiemetic prophylaxes reported the highest effectiveness to prevent PONV for the NK1 receptor antagonist aprepitant (relative risk, RR 0.26), followed by ramosetron (RR 0.44), granisetron (RR 0.45), dexamethasone (RR 0.51) and ondansetron (RR 0.55), thereby revising the dogma that every antiemetic is equally effective. Adverse events of antiemetics were generally rare and reported in less than half of the included studies, yielding a low quality of evidence for these end points. In general, combinations of different antiemetics were more effective than single prophylaxes. In children above 3 years of age, the same principles should be applied as in adults. For these patients, there is a high degree of evidence for the combination of dexamethasone and 5‑HT3 receptor antagonists. When PONV occurs, the consensus guidelines suggest that antiemetics from a class different than given as prophylaxis should be administered. To decrease the incidence of PONV and increase the quality of care, the importance of the implementation of institutional-level guidelines and protocols as well as assessment of PONV prophylaxis and PONV incidence is highly recommended.
UNASSIGNED: Auch wenn für Anästhesiologen über Jahrzehnte die Prophylaxe und Therapie postoperativer Schmerzen im Rahmen des postoperativen Patientenkomforts an vorderster Stelle standen, ist das Auftreten von postoperativer Übelkeit und postoperativem Erbrechen (PONV) aus Patientensicht ein höchst relevantes Ereignis mit einem sehr ähnlichen Stellenwert. Entsprechend aktueller konsensusbasierter Empfehlungen soll bei allen Patienten das Ausgangsrisiko für PONV möglichst niedrig gehalten (z. B. durch den gezielten Einsatz von Regionalanästhesieverfahren) und ein erhöhtes Risiko anhand gängiger Risikoklassifizierungen identifiziert werden. Generell wird zu einer liberalen Verabreichung einer Prophylaxe geraten, im Zweifel auch unabhängig von Risikoabschätzungen. Eine Prophylaxe mit 2 Antiemetika, wie z. B. die Gabe von Dexamethason in Kombination mit einem 5‑HT3-Rezeptor-Antagonisten, kann in vielen Szenarien die Basis für alle Patienten darstellen und soll bei hohem Risiko um Dritt- und Viertprophylaxen aus weiteren Substanzklassen ergänzt werden. Eine kürzlich publizierte, umfassende Cochrane-Übersichtsarbeit zum Vergleich der Wirksamkeit verfügbarer Antiemetika konnte für die Wirkstoffklasse der NK1-Rezeptor-Antagonisten die höchste Effektivität im Hinblick auf die Vermeidung postoperativen Erbrechens feststellen. Generell waren Kombinationen unterschiedlicher Antiemetika effektiver als Einfachprophylaxen. Bei Kindern ab dem 3. Lebensjahr gelten die gleichen Grundsätze zur PONV-Prophylaxe wie bei Erwachsenen. Für diese Patientengruppe liegt ein hoher Grad an Evidenz für die Kombination von Dexamethason und 5‑HT3-Antagonisten vor. Zur Therapie von PONV sollten gemäß Leitlinienempfehlung Pharmaka aus Substanzklassen eingesetzt werden, die noch nicht im Rahmen der Prophylaxe gegeben wurden.

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Nerve conduction studies and needle electromyography, collectively known as electrodiagnostic (EDX) studies, have been available for pediatric patients for decades, but the accessibility of this diagnostic modality and the approach to testing vary significantly depending on the physician and institution. The maturation of molecular diagnostic approaches and other diagnostic technologies such as neuromuscular ultrasound indicate that an analysis of current needs and practices for EDX studies in the pediatric population is warranted. The American Association of Neuromuscular & Electrodiagnostic Medicine convened a consensus panel to perform literature searches, share collective experiences, and develop a consensus statement. The panel found that electrodiagnostic studies continue to have high utility for the diagnosis of numerous childhood neuromuscular disorders, and that standardized approaches along with the use of high-quality reference values are important to maximize the diagnostic yield of these tests in infants, children, and adolescents.

Background: Published reports of continuous palliative sedation therapy (CPST) suggest heterogeneity in practice. There is a paucity of reports that compare practice with clinical guidelines. Objectives: To assess adherence of continuous palliative sedation practices with criteria set forth in local clinical guidelines, and to describe other features including prevalence, medication dosing, duration, multidisciplinary team involvement, and concurrent therapies. Design: Retrospective chart review. Settings/Subjects: We included cases in which a midazolam infusion was ordered at the end of life. Study sites included four adult hospitals in the Calgary health region, two hospices, and a tertiary palliative care unit. Measurements: Descriptive data, including proportion of deaths involving palliative sedation therapy, number of criteria documented, midazolam dose/duration, concurrent symptom management therapies, and referrals to spiritual care, psychology, or social work. Results: CPST occurred in 602 out of 14,360 deaths (4.2%). Full adherence to criteria occurred in 7% of cases. The most commonly missed criteria were: a \"C2\" goals-of-care designation order (comfort care focus in the imminently dying) (84%) and documentation of imminent death in the chart (55%). Concurrent medical therapies included opioids in 98% of cases and intravenous hydration in 85% of cases. Few referrals were made to multidisciplinary care teams. Conclusions: We found low adherence to palliative sedation guidelines. This may reflect the perception that some criteria are redundant or clinically unimportant. Future work could include a study of barriers to guideline uptake, and guideline modification to provide direction on concurrent therapies and multidisciplinary team involvement.

BACKGROUND: Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine 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 patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi-round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures.
RESULTS: We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0-6 h, 6-24 h, and overall), one of two quality-of-recovery (QoR) scales (QoR score or QoR-15), time to gastrointestinal recovery, time to mobilisation, and sleep quality.
CONCLUSIONS: As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

Infants of age less than one year have the highest mortality rate in pediatrics. The American Academy of Pediatrics published guidelines for palliative care in 2013; however, significant variation persists among local protocols addressing neonatal comfort care at the end-of-life (EOL).
The purpose of this study was to evaluate current neonatal EOL comfort care practices and clinician satisfaction across America.
After institutional review board approval (516005), an anonymous, electronic survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Members of the listserv include neonatologists, neonatal fellow physicians, neonatal nurses, and neonatal nurse practitioners from across America (U.S. and Canada).
There were 346/3000 (11.5%) responses with wide geographic distribution and high levels of intensive care responding (46.1% Level IV, 50.9% Level III, 3.0% Level II). Nearly half (45.2%) reported that their primary institution did not have neonatal comfort care guidelines. Of those reporting institutional neonatal comfort care guidelines, 19.1% do not address pain symptom management. Most guidelines also do not address gastrointestinal distress, anxiety, or secretions. Thirty-nine percent of respondents stated that their institution did not address physician compassion fatigue. Overall, 91.8% of respondents felt that their institution would benefit from further education/training in neonatal EOL care.
Across America, respondents confirmed significant variation and verified many institutions do not formally address neonatal EOL comfort care. Institutions with guidelines commonly appear to lack crucial areas of palliative care including patient symptom management and provider compassion fatigue. The overwhelming majority of respondents felt that their institutions would benefit from further neonatal EOL care training.

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BACKGROUND: Evidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events.
METHODS: In this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico.
RESULTS: Ninety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8-10] vs. 10 [IQR 10-10], P<.001 and 10 [IQR 9-10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47).
CONCLUSIONS: Compared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction.
BACKGROUND: NCT02820051.

For improved utilization of the existing palliative care team in the intensive care unit (ICU), a process was needed to identify patients who might need a palliative care consultation in a timelier manner.
A systematic method to create a new program that would be compatible with our specific ICU environment and patient population was developed. A literature review revealed a fairly extensive array of reports and numerous clinical practice guidelines, which were assessed for information and strategies that would be appropriate for our unit.
The recommendations provided by the Center to Advance Palliative Care from its Improving Palliative Care in the ICU project were used to successfully implement a new palliative care initiative in our ICU.
The guidelines provided by the Improving Palliative Care in the ICU project were an important tool to direct the development of a new palliative care ICU initiative.

BACKGROUND: Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting.
METHODS: We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature.
RESULTS: A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round.
CONCLUSIONS: We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.