Anesthesia and analgesia
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Anesthesia and analgesia · Jul 2019
Meta AnalysisKetamine Infusions for Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Why?
Although often used to manage chronic pain acutely, the longer-term benefits of ketamine infusions remain uncertain. Despite this there has been significant growth in using ketamine infusions to treat chronic pain, rationalised by ketamine’s expected effect to reduce central sensitisation.
What?
This meta-analysis identified a small benefit for up to two weeks after a ketamine infusion, although little evidence of longer-term benefit. There appears to be a dose-response effect, suggesting greater efficacy with high-dose ketamine infusions.
The underlying problem...
Most research on ketamine infusions focuses on perioperative analgesia. Trials invetsigating ketamine infusions for chronic pain are universally small, lack standardisation and are often low quality.
This meta-analysis unfortunately does not add clarity to the question of whether ketamine infusions have long-term benefit in chronic pain syndromes. Clinicians will continue to need to judge indication on a case-by-case basis...
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Anesthesia and analgesia · Jul 2019
ReviewSafety of Beach Chair Position Shoulder Surgery: A Review of the Current Literature.
Although uncommon, severe neurological events have been reported in patients undergoing shoulder surgery in the beach chair position. The presumed etiology of central nervous system injury is hypotension and subsequent cerebral hypoperfusion that occurs after alterations in positioning under general anesthesia. Most clinical trials have demonstrated that beach chair positioning results in reductions in regional brain oxygenation, cerebral blood flow, and jugular bulb oxygenation, as well as impairment in cerebral autoregulation and electroencephalographic/processed electroencephalographic variables. Further studies are needed to define the incidence of adverse neurological adverse events in the beach chair position, identify the best intraoperative neurological monitors that are predictive of neurocognitive outcomes, the lowest "safe" acceptable blood pressure during surgery for individual patients, and the optimal interventions to treat intraoperative hypotension.
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Anesthesia and analgesia · Jul 2019
ReviewEvidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery.
Why is this important?
With obesity rates over 40% in many industrialised countries, and accelerating growth in bariatric surgery for more than a decade, there is need for evidence based guidelines to direct perioperative care.
This evidence review was conducted to identify protocols that achieve "superior outcomes, reduced length of hospital stay, and cost savings" for bariatric patients.
Many of the institutional protocols were founded on ERAS principals originating with colorectal surgery.
Ok, what did they identify?
The AHRQ made evidence-based anesthesia recommendations across three areas:
- Preoperative: reduce fasting; provide carbohydrate loading; multimodal preanesthesia medication.
- Intraoperative: standardised intraoperative anesthesia; protective ventilation; goal-directed fluid therapy (minimization); postop nausea and vomiting prophylaxis.
- Postoperative: multimodal analgesia.
Reality check
These protocols largely reflect 'good quality modern anesthesia', and there is little here that is specific to bariatric patients.
This is not a critcism, but a reminder that it's consistent and holistic application of quality anesthesia across the perioperative period that improves outcomes – especially among higher risk patients. Interventions do not need to be fancy, just quality principles consistently applied.
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Anesthesia and analgesia · Jul 2019
ReviewPoint-of-Care Blood Testing: The Technology Behind the Numbers.
Minutes count in the operating room when it comes to treatment guidance and therapies. On a daily basis, anesthesiologists make hundreds of decisions, some based on laboratory results, when guiding patient therapies. ⋯ Providers should be aware of the limitations, including the potential for error in results-errors that could lead to improper treatment and possible patient harm. This article outlines the technical aspects and summarizes pitfalls in accuracy for 2 of the most commonly utilized point-of-care testing devices: glucose meters and hemoglobin meters.
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Anesthesia and analgesia · Jul 2019
ReviewIntraluminal Pulmonary Vein Stenosis in Children: A "New" Lesion.
Pulmonary vein stenosis (PVS) is a rare disorder that leads to progressive narrowing of the extrapulmonary veins. PVS has been reported in both children and adults and in its worse iteration leads to pulmonary hypertension, right ventricular failure, and death. Multiple etiologies of PVS have been described in children and adults. ⋯ Lung transplantation has been used as an alternative treatment strategy for end-stage, refractory PVS. Nonetheless, despite the different innovative approaches used, morbidity and mortality remain high. At present, the preferred treatment strategy is frequent reassessment of disease progression to guide use of catheter-based and surgical interventions in conjunction with medical therapy.