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This chapter presents a case study on an 86-year-old retired accountant, experiencing worsening symptoms and signs of congestive heart failure. The patient clearly understood and accepted the balance of benefits versus risks, and gave informed consent to the procedure. Offering the operation is respectful of the ethical principle of autonomy. The patient's primary goals were to improve his functionality and reduce his symptoms even with a substantial risk of dying. The chapter discusses questions that need to be addressed when the outcome of the intervention is poor and the possibilities of achieving the patient's stated goals are virtually nil. The focus should be on the overall trend and not the minor ups and downs of vital signs, drug infusion rates, ventilatory settings, etc. It is important to recognize that it will take time, perhaps days, for the family to grasp the lack of improvement or deterioration in the patient's condition.
This chapter reviews alternative and adjunctive modes of delivering postoperative analgesia, and summarises what is known about efficacy and outcome. It presents the evidence for the commonly utilised analgesic modalities as they pertain to postoperative outcome in light of our overall goal of rapid return to normal physiologic function after surgery and the increasing movement towards a multimodal approach to analgesia. Randomised trials and meta-analyses overwhelmingly support the superior analgesic efficacy of epidural analgesia compared with "conventional analgesia" and patient-controlled analgesia (PCA) administered opioids. Multiple studies, and meta-analyses, confirm an average 30-50% opioid-sparing effect of NSAIDs. The focus of postoperative pain trials has been on assessing new modes of analgesia with particular regard both to their analgesic efficacy and to their ability to improve surgical outcome. Epidural analgesia offers a number of distinct benefits and appears to hasten recovery.
Mina Nishimori, Department of Anesthesia/Critical Care, Massachusetts General Hospital, Boston, MA, USA,
Jane Ballantyne, Department of Anesthesia, Massachusetts General Hospital, Pain Center, Boston, MA, USA
The debate over the theoretical superiority of regional over general anaesthesia has persisted throughout most of the twentieth century, and there is still no satisfactory answer to the question of whether avoidance of general anaesthesia saves lives or reduces morbidity. This chapter reviews and analyses the evidence supporting an effect on surgical outcome of anaesthetic choice. For carotid endarterectomy, using regional anaesthesia rather than general anaesthesia enables keeping patients awake during carotid artery clamping. The chapter summarizes the key evidence supporting advantages or disadvantages of intraoperative neuraxial anaesthesia on postoperative outcomes. It also discusses selected topics regarding postoperative outcome after sole regional anaesthesia versus general anaesthesia. Meta-analysis and systematic reviews are cited, and emphasis is given to randomised controlled trials (RCTs). Evidence suggests the possibility of reduced mortality among several specific patient populations such as hip fracture surgery under spinal anaesthesia.
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