Current opinion in anaesthesiology
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Recent randomized clinical trials have demonstrated strong efficacy of endovascular therapy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions; in the USA alone, tens of thousands of patients annually may benefit. The impact of the type of anesthesia used during mechanical thrombectomy on patient outcomes remains controversial. This review discusses the current literature on the effects of anesthesia type on patient outcome following endovascular stroke therapy. ⋯ Retrospective reports, and the 2015 American Heart Association/American Stroke Association Guideline (focused update of the 2013 guidelines for the early management of patients with AIS regarding endovascular treatment) based on these reports, are in favor of sedation (conscious sedation) over general anesthesia for endovascular stroke thrombectomy. However, the two randomized controlled prospective studies published provide inconclusive evidence as to the best anesthetic practice for endovascular stroke therapy. More randomized clinical trials are needed to optimize anesthetic patient care in AIS.
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Enthusiasm for regional anesthesia has been driven by multimodal benefits to patient outcomes. Despite widespread awareness and improved techniques (including the increasing use of ultrasound guidance for block placement), intravascular sequestration and the attendant risk of local anesthetic systemic toxicity (LAST) remains. Intravenous lipid emulsion (ILE) for the treatment of LAST has been endorsed by anesthetic regulatory societies on the basis of animal study and human case report data. The accumulated mass of reporting now permits objective interrogation of published literature. ⋯ Lipid emulsion remains first-line therapy (in conjunction with standard resuscitative measures) in LAST. Increasing conjecture as to the clinical efficacy of ILE in LAST, however, calls for high-quality human data to refine clinical recommendations.
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With an ultimate aim of improving patients overall outcome and satisfaction, minimally invasive surgical approach is becoming more of a norm. The related anesthetic evidence has not expanded at the same rate as surgical and technological advancement. This article reviews the recent evidence on anesthesia and perioperative concerns for patients undergoing minimally invasive neurosurgery. ⋯ Over the last year, little new information has been added to existing literature regarding anesthesia for minimally invasive neurosurgeries. Neuroanesthesia goals remain the same and less invasive surgical techniques do not translate into safe anesthesia. Specific concerns for each procedure should be taken into consideration.
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Curr Opin Anaesthesiol · Oct 2017
ReviewCriteria for Intensive Care admission and monitoring after elective craniotomy.
The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy. ⋯ After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring.
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Curr Opin Anaesthesiol · Oct 2017
ReviewChemotherapy-induced peripheral neuropathy: a review of recent findings.
Chemotherapy-induced peripheral neuropathy (CIPN) is a common, frequently chronic condition characterized by pain and decreased function. Given the growing number of cancer survivors and an increasing recognition of opioid therapy limitations, there is a need for critical analysis of the literature in directing an informed and thoughtful approach for the management of painful CIPN. ⋯ Despite the volume of recent publications, there are limited preventive or therapeutic strategies for CIPN supported by high-level evidence. Duloxetine remains the only pharmacologic agent with demonstrated benefit; its clinical use should be routinely considered. Moving forward, nonopioid analgesic therapies will likely play an increasing role in CIPN treatment, but further research is necessary to confirm their utility. Promising therapies include vitamin B12 supplementation, physical therapy, and various forms of neuromodulation.