Anesthesia and analgesia
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Anesthesia and analgesia · Aug 2008
ReviewCoronary artery stents: Part I. Evolution of percutaneous coronary intervention.
The subspecialty of interventional cardiology has made significant progress in the management of coronary artery disease over the past three decades with the development of percutaneous coronary transluminal angioplasty, atherectomy, and bare-metal and drug-eluting stents (DES). Bare-metal stents (BMS) maintain vessel lumen diameter by acting as a scaffold and prevent collapse incurred by angioplasty. However, these devices cause neointimal hyperplasia leading to in-stent restenosis and requiring reintervention in more than 20% of patients by 6 mo. ⋯ Since the introduction of percutaneous transluminal coronary angioplasty for the treatment of coronary atherosclerosis, the practice of percutaneous coronary intervention has undergone a dramatic transformation from simple balloon dilation catheters to sophisticated mechanical endoprostheses. These advancements have impacted the practice of perioperative medicine. In this series of two articles, in Part I we will review the evolution of percutaneous coronary intervention and discuss the issues associated with percutaneous transluminal coronary angioplasty and coronary stenting; in Part II we will discuss perioperative issues and management strategies of coronary stents during noncardiac surgery.
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Anesthesia and analgesia · Aug 2008
Review Comparative StudyFactors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia.
The spread of sensory blockade after epidural injection of a specific dose of local anesthetic (LA) differs considerably among individuals, and the factors affecting this distribution remain the subject of debate. Based on the results of recent investigations regarding the distribution of epidural neural blockade, specifically for thoracic epidural anesthesia, we noted that the total mass of LA appears to be the most important factor in determining the extent of sensory, sympathetic, and motor neural blockade, whereas the site of epidural needle/catheter placement governs the pattern of distribution of blockade relative to the injection site. ⋯ However, combinations of several patient and technical factors may aid in predicting LA dose requirements. Based on these results, we have also formulated suggested epidural insertion sites that may optimize both analgesia and sympathicolysis for various surgical indications.
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Anesthesia and analgesia · Aug 2008
ReviewCoronary artery stents: II. Perioperative considerations and management.
The management of patients with coronary artery stents during the perioperative period is one of the most important patient safety issues clinicians confront. Perioperative stent thrombosis is a life-threatening complication for patients with either bare-metal or drug-eluting stents. Noncardiac surgery appears to increase the risk of stent thrombosis, myocardial infarction, and death, particularly when patients undergo surgery early after stent implantation. ⋯ We present considerations for regional anesthesia, as well as postoperative recommendations as the occurrence of perioperative stent thrombosis appears to be greatest during this period. Immediate percutaneous coronary intervention is the definitive treatment for perioperative stent thrombosis, and 24-h access to an interventional cardiology suite should be readily available. Algorithms for perioperative management of patients with bare-metal and drug-eluting stents are proposed.
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Anesthesia and analgesia · Aug 2008
ReviewLife after death: the aftermath of perioperative catastrophes.
Most anesthesiologists will experience the perioperative death of a patient or a major perioperative catastrophe in the course of their careers. Anesthesia training, however, does not prepare individuals to handle the aftermath of such a stressful event. Multiple surveys have shown that the death of a patient has a major emotional impact on up to 75% of health care providers involved, regardless of whether the death was expected or whether the patient was well known to the practitioner. ⋯ The negative consequences of failure to cope well after these events are significant to individuals and health care systems alike. Further study into the short-term and long-term impact of perioperative catastrophes on providers and health systems is needed. Additionally, education on how to handle the aftermath of perioperative catastrophes and formal support structures should be provided to practitioners at all levels of training.
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Anesthesia and analgesia · Aug 2008
ReviewPediatric mastocytosis: routine anesthetic management for a complex disease.
Pediatric mastocytosis consists of a spectrum of clinical variants characterized by increased numbers of resident mast cells in various organ systems. Mast cells are instrumental in mediating anaphylaxis and patients with mastocytosis are at risk to develop provoked and unprovoked episodes of anaphylaxis. ⋯ We reviewed the main features of pediatric mastocytosis, its anesthetic and perioperative implications, and describe a practical approach to the anesthetic management of pediatric patients with the disease. Although many drugs used routinely in anesthesia reportedly caused mast cell degranulation, deviations from routine anesthesia techniques are not necessarily warranted. However, an understanding of the anesthetic implications of the disease and meticulous preparation to treat possible adverse events are advised.