Anesthesia and analgesia
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Anesthesia and analgesia · Jun 2015
Comparative StudyRegional Versus General Anesthesia in Surgical Patients with Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce the Risk of Postoperative Complications?
This retrospective propensity-matched cohort study, used 5 years of data to study 2,644 matched pairs-of-patients with a preoperative diagnosis of severe COPD.
Important exclusions were patients already ventilated, already with pulmonary infections, along with cardiac, emergency & transplant surgery, and those receiving repeat surgery within 30 days.
Receiving general anesthesia was associated with a 43% higher risk of respiratory infection (3.3% vs 2.3%, P = 0.0384), 133% greater risk of prolonged ventilation (2.1% vs 0.9%, P = 0.0008) and 44% greater risk of unplanned post-op intubation (2.6% vs 1.8%, P = 0.0487), when compared with regional anesthesia.
Nonetheless there was no significant mortality difference at 30 days (3.0% vs 2.7%, P = 0.6788).
The mix of regional techniques was 341 epidural, 1713 spinal, and 590 peripheral blocks. Notably, sub-group analysis of epidural-patients showed no difference in pulmonary complications or composite morbidity between epidural and general anesthesia. (Though given relatively small number of epidural patients, this might reflect a lack of power).
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Anesthesia and analgesia · Jun 2015
ReviewThe evolution of perioperative transfusion testing and blood ordering.
The evolution of modern anesthesia and surgical practices has been accompanied by enhanced supportive procedures in blood banking and transfusion medicine. There is increased focus on the preparation and the use of blood components including, but not limited to, preventing unnecessary type and screen/crossmatch orders, decreasing the time required to provide compatible red blood cells (RBCs), and reducing the waste of limited blood and personnel resources. The aim of this review is to help the anesthesiologist and surgical staff identify patients at highest risk for surgical bleeding. ⋯ The updated maximum surgical blood ordering schedule reflects modern practices, such as laparoscopy, improved surgical techniques, and use of hemostatic agents resulting in a more streamlined process for ordering and obtaining RBCs. The electronic (computer) crossmatch and electronic remote blood issue have also dramatically reduced the amount of time required to obtain crossmatch-compatible RBCs when compared with the more traditional serologic crossmatch methods. These changes in blood banking methods have resulted in more efficient delivery of blood to surgical patients.
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Portable infrared pupillometers provide an objective measure of pupil size and pupillary reflexes, which for most clinicians was previously only a visual impression. But despite the fact that pupillometry can uncover aspects of how the human pupil reacts to drugs and noxious stimulation, the use of pupillometry has not gained widespread use among anesthesiologists and critical care physicians. The present review is an introduction to the physiology of pupillary reflexes and the currently established clinical applications of infrared pupillometry, which will hopefully encourage physicians to use this diagnostic tool in their clinical practice. ⋯ Use of these instruments has uncovered aspects of how the human pupil reacts to drugs and noxious stimulation. The primary clinical applications for portable pupillometry have been in the assessment of brainstem function. Portable pupillometry is useful in the management of pain because it allows for assessments of the effect of opioids and in the titration of combined regional-general anesthetics.
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Premature birth is a significant cause of infant and child morbidity and mortality. In the United States, the premature birth rate, which had steadily increased during the 1990s and early 2000s, has decreased annually for 7 years and is now approximately 11.39%. Human viability, defined as gestational age at which the chance of survival is 50%, is currently approximately 23 to 24 weeks in developed countries. ⋯ Finally, because therapy and supportive care continue to change, the outcomes of extremely low birth weight infants are ever evolving. Efforts to minimize injury, preserve growth, and identify interventions focused on antioxidant and anti-inflammatory pathways are now being evaluated. Thus, treating and preventing long-term deficits must be developed in the context of a "moving target."
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Anesthesia and analgesia · Jun 2015
ReviewChronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations.
Chronic opioid use has been associated with the development of sleep-disordered breathing (SDB) such as central sleep apnea (CSA). Patients receiving chronic opioids may suffer from unrecognized sleep apnea that contributes to opioid-overdose death. Currently, information regarding the perioperative management of patients with chronic opioid-associated CSA is limited. The objectives of this review are to define the clinical manifestations of SDB associated with chronic opioid therapy, especially CSA, and to highlight their prevalence, mechanisms, risk factors, and perioperative management. ⋯ The overall prevalence of CSA in patients taking chronic opioids was 24%. The most important risk factors for severity of CSA were an MEDD >200 mg, and low or normal body mass index. Continuous positive airway pressure is often ineffective for treating CSA. Limited data are available on the perioperative management of patients with CSA associated with chronic opioid use. Further prospective studies on the perioperative risks and management of these patients are needed.