Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2010
ReviewGlucose management in the neurosurgical patient: are we yet any closer?
This review focuses on recent findings in perioperative management of blood glucose control using intensive insulin therapy in neurosurgical and neurocritical care and in other intensive care unit patients. We also aim to address practical issues and make recommendations that may contribute to the safe clinical application of intensive insulin therapy targeted to optimize blood glucose control in these patients. ⋯ In neurosurgical and neurocritical care as well as other intensive care unit patients, both hypoglycemia and hyperglycemia have significant adverse effects. The optimal glucose level remains under debate but significant steps have evolved with the call for judicious control and elimination of the historical approach to glycemic management, which underestimated drawbacks associated with dysglycemia. The increased incidence of hypoglycemia and mortality as well as the impact of hyperglycemia on worsening neurologic function in patients with acute brain damage heightens the need for more clinical studies on perioperative glucose management in these patients.
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Curr Opin Anaesthesiol · Oct 2010
ReviewIndications and management of continuous infusion of local anesthetics at home.
The review examines recent research activity in the field of continuous peripheral nerve blocks in the ambulatory setting and places it in context with regard to previous research efforts. ⋯ Continuous peripheral nerve blockade at home offers good short-term control of postoperative pain in the outpatient setting. Long-term outcomes remain to be evaluated fully. More information is becoming available on local anesthetic volume and concentration relationships in both the upper and lower extremities--optimal strategies are not yet clear. Ultrasound may offer benefits in terms of speed and ease of continuous catheter placement while reducing the necessary number of needle passes required to reach the target structure site(s).
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Objective monitors to warn against adverse events specific to the performance of nerve blockade are relatively unsophisticated compared with monitors used during general anesthesia. The purpose of this review is to outline the various monitors available, and how they can be used to reduce nerve block-related complications. ⋯ Peripheral nerve blockade has evolved from an entirely blind procedure to a more reproducible subspecialty. Several monitors exist to objectively guide and monitor needle placement and application of local anesthetics. Because these monitors are complementary, best practice may involve combining all of these monitoring options when performing peripheral nerve blocks.
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Endoscopic neurosurgical procedures are becoming more frequent and popular in the treatment of intracranial disease. When endoscopy involves the intraventricular structures, irrigating solutions are required and may contribute to sudden and sharp increases in intracranial pressure. More recently, nasal endoscopic approach has been used to perform skull base surgery for aneurysms and tumours. We have analysed published articles in order to detect anaesthesia management and perioperative complications. ⋯ Invasive arterial blood pressure and intracranial pressure should be measured continuously during neuroendoscopies to detect early intraoperative cerebral ischaemia instead of waiting for the appearance of bradycardia which may be a late sign. General anaesthesia remains the technique of choice. Intracranial haemorrhage increases the likelihood of perioperative complications. Close postoperative monitoring is required to diagnose and treat complications such as convulsions, persistent hydrocephalus, haemorrhage or electrolytic imbalance.
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Curr Opin Anaesthesiol · Oct 2010
ReviewFrom basic concepts to emerging technologies in regional anesthesia.
The present article details how our understanding of the basic concepts of regional anesthesia has recently evolved. We will appraise current technological advances and question the commensurate nature of the relationship between tradition and innovation. ⋯ Over the past decade, our understanding of the fundamental concepts of regional anesthesia continues to be challenged by emerging experimental and clinical evidence.