Anesthesia and analgesia
Review Meta Analysis
Remifentanil is an ultrashort-acting opioid with favorable pharmacokinetic properties that make it suitable as a labor analgesic. Although it crosses the placenta freely, it is eliminated quickly in the neonate by rapid metabolism and redistribution. We aimed to determine whether remifentanil compared with meperidine is effective in reducing pain scores in laboring parturients. Other effects on the mother, the labor process, and the neonate were also examined. ⋯ Compared with meperidine, remifentanil is superior in reducing mean VAS scores for labor pain after 1 hour.
Randomized Controlled Trial
Clopidogrel (Plavix®) therapy, although effective for minimizing risk of thrombotic events, is also associated with potential bleeding risk. Recombinant activated FVII (rFVIIa, NovoSeven®) induces hemostasis in hemophilia patients with inhibitors (alloantibodies) and has been proposed as potential treatment for mitigating clopidogrel therapy-mediated bleeding. ⋯ In this clinical study, rFVIIa (10 and 20 μg/kg) reversed the effect of clopidogrel on blood loss.
Diagnosing postoperative heparin-induced thrombocytopenia (HIT) in cardiothoracic surgical patients is complicated because of the profound thrombocytopenia that occurs with cardiopulmonary bypass (CPB). CPB predisposes patients to develop a frequent incidence of antibodies directed against platelet factor 4 (PF4)/heparin complexes and HIT. The sensitivity of readily available antibody immunoassays is high, but specificity is quite low. The use of both a clinical probability score and rapid laboratory immunoassay has been shown to increase specificity, which is of particular importance in the CPB setting. Prompt diagnosis is crucial because cessation of heparin and treatment with alternative anticoagulation can reduce the risk of thromboembolic events. ⋯ We demonstrated that the use of the 4Ts clinical score combined with the PF4/heparin immunoassay for HIT diagnosis increases the sensitivity and specificity of HIT testing compared with the PF4/heparin immunoassay alone. Furthermore, with an intermediate 4Ts score and positive PF4/heparin antibody test, a confirmatory platelet activation assay such as the SRA is necessary. Physicians treating patients after cardiothoracic surgery should recognize the need for an antibody test and confirmation with a platelet activation assay with even moderate clinical probability of HIT.
Lidocaine is used clinically for tactile allodynia associated with diabetes-induced neuropathy. Although the analgesic effect of lidocaine through suppression of microglial activation has been implicated in the development of injury-induced neuropathic pain, its mechanism of action in diabetes-induced tactile allodynia has not yet been completely elucidated. ⋯ Lidocaine alleviates STZ-induced tactile allodynia, possibly by modulating the p38 pathway in spinal microglial cells. Inhibiting microglial activation by lidocaine treatment early in the course of diabetes-induced neuropathy represents a potential therapeutic strategy for tactile allodynia.
Randomized Controlled Trial Comparative Study
Hip arthroplasty frequently requires potent postoperative analgesia, often provided with an epidural or posterior lumbar plexus local anesthetic infusion. However, American Society of Regional Anesthesia guidelines now recommend against epidural and continuous posterior lumbar plexus blocks during administration of various perioperative anticoagulants often administered after hip arthroplasty. A continuous femoral nerve block is a possible analgesic alternative, but whether it provides comparable analgesia to a continuous posterior lumbar plexus block after hip arthroplasty remains unclear. We therefore tested the hypothesis that differing the catheter insertion site (femoral versus posterior lumbar plexus) after hip arthroplasty has no impact on postoperative analgesia. ⋯ After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion.