Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2019
Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part I-Femoral Nerve Block.
The optimal management of pain after ambulatory anterior cruciate ligament reconstruction (ACLR) is unclear. Femoral nerve block (FNB) is purported to enhance postoperative analgesia, but its effectiveness in the setting of modern multimodal analgesia is unclear. This systematic review examines the effect of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, whether or not the analgesic regimen used included local instillation analgesia (LIA). ⋯ The effect of FNB on long-term quadriceps strength or function after ACLR was not evaluated in the reviewed trials. Contemporary evidence suggests that the benefits of adding FNB to multimodal analgesia for ACLR are modest and conflicting, but there is no incremental analgesic benefit if the multimodal analgesic regimen included LIA. Our findings do not support the routine use of FNB for analgesia in patients having ACLR.
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Anesthesia and analgesia · Jan 2019
Meta AnalysisRegional Analgesia Added to General Anesthesia Compared With General Anesthesia Plus Systemic Analgesia for Cardiac Surgery in Children: A Systematic Review and Meta-analysis of Randomized Clinical Trials.
The aim of this systematic review was to compare the effects of regional analgesic (RA) techniques with systemic analgesia on postoperative pain, nausea and vomiting, resources utilization, reoperation, death, and complications of the analgesic techniques in children undergoing cardiac surgery. ⋯ Compared to systemic analgesia, RA techniques reduce postoperative pain up to 24 hours in children undergoing cardiac surgery. Currently, there is no evidence that RA for pediatric cardiac surgery has any impact on major morbidity and mortality. These results should be interpreted cautiously because they represent a meta-analysis of small and heterogeneous studies. Further studies are needed.
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There is a continued mandate for practicing evidence-based medicine and the prerequisite rigorous analysis of the comparative effectiveness of alternative treatments. There is also an increasing emphasis on delivering value-based health care. Both these high priorities and their related endeavors require correct information about the outcomes of care. ⋯ Assessing validity is answering whether the instrument is actually measuring what it is intended to measure. This includes content validity, criterion validity, and construct validity. In evaluating a reported set of research data and its analyses, in a similar manner, it is important to assess the overall internal validity of the attendant study design and the external validity (generalizability) of its findings.
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Anesthesia and analgesia · Jan 2019
ReviewBivalirudin for Pediatric Procedural Anticoagulation: A Narrative Review.
Bivalirudin (Angiomax; The Medicines Company, Parsippany, NJ), a direct thrombin inhibitor, has found increasing utilization as a heparin alternative in the pediatric population, most commonly for the treatment of thrombosis secondary to heparin-induced thrombocytopenia. Due to the relative rarity of heparin-induced thrombocytopenia as well as the lack of Food and Drug Administration-approved indications in this age group, much of what is known regarding the pharmacokinetics and pharmacodynamics of bivalirudin in this population has been extrapolated from adult data. This narrative review will present recommendations regarding the use of bivalirudin for procedural anticoagulation in the pediatric population based on the published literature.
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Anesthesia and analgesia · Jan 2019
Review Practice GuidelineSociety of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery.
Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30%-50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. ⋯ Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk to develop poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion and based on published risk score models for poAF. This approach allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is our hope that these new additions to the clinical toolkit for the management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.