Anesthesia and analgesia
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Anesthesia and analgesia · Sep 2008
ReviewA systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia.
Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research. ⋯ Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.
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It is now well recognized that low cerebral blood flow (and cerebral perfusion pressure (CPP)) is associated with poor outcome after traumatic brain injury. What is less clear is whether altering cerebral blood flow or CPP will lead to clinical improvement. Initial studies indicated that increasing CPP may be beneficial and the Brain Trauma Foundation acknowledged this by incorporating a target of 70 mm Hg in the 1996 guidelines. ⋯ Furthermore, with the advent of advanced neuromonitoring techniques, clinicians are able to more closely monitor the effects of hemodynamic manipulations on cerebral metabolism. As yet, there is no strong outcome evidence to support this approach. Until then, the current debate over the optimal approach to CPP management is likely to continue.
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Anesthesia and analgesia · Sep 2008
ReviewRespiratory depression after neuraxial opioids in the obstetric setting.
Neuraxial opioids have contributed significantly to improved labor and postcesarean delivery analgesia. In the obstetric population, epidural and intrathecal opioids are associated with a very low risk of clinically significant respiratory depression. Although rare, respiratory depression is a serious risk; patients may die or suffer permanent brain damage as a consequence. This review discusses the mechanism and incidence, as well as the prevention, detection, and management of respiratory depression with morphine, extended-release epidural morphine, and lipophilic opioids in the labor and cesarean delivery setting.