Current opinion in anaesthesiology
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Thoracic epidural anesthesia (TEA) is most frequently used after major surgery. However, despite ongoing research, the influence of TEA on the intestinal perioperative pathophysiology is not fully understood. ⋯ Further research concerning the use of TEA in major laparoscopic procedures and its potential to improve or endanger anastomotic healing is warranted. The experimental studies of TEA in critical illness should be expanded.
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Curr Opin Anaesthesiol · Oct 2009
ReviewLocal anaesthetic adjuvants: neuraxial versus peripheral nerve block.
To present a review of the literature on the importance and the clinical characteristics relevant to adjuvants added to local anaesthetics in neuraxial and peripheral nerve blocks. ⋯ Opioids and alpha-2 receptor agonists are important as neuraxial adjuvants to improve the quality of peroperative and postoperative analgesia in high-risk patients and in ambulatory procedures. In peripheral nerve blocks, however, some benefit is found only when clonidine is added to local anaesthetics under certain circumstances.
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The use of pharmacological thromboprophylaxis in the perioperative period may conflict with regional anesthetic techniques in which maintaining hemostatic integrity is essential. Recently, new anticoagulants have been developed with more efficacy and a better safety profile. This article reviews the basis for the actual recommendations and the current status and management of these new drugs. ⋯ When new anticoagulant drugs are used for thromboprophylaxis in orthopedic surgery, the performance of neuraxial anesthetic techniques should be based on their pharmacology. If a peripheral blockade is chosen, these recommendations should be followed when a block is performed in a noncompressible area.
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Sedation is a well recognized technique to improve patients' acceptance and comfort during regional anesthesia. The use of this technique is growing exponentially and is nowadays applied not only in the operating room but also in many other different locations within and outside the hospital. ⋯ The explosion of sedation well beyond the world of regional anesthesia has raised new challenges. Some sedative procedures will be performed more and more often by nonanesthesiologists in the future. This trend is inevitable due to limited resources and stresses on the importance of building up education and teaching programs for nonanesthesiologists. The need for reliable devices for monitoring of sedation and new hypnotics, which have even better phamacokinetics than those available, are needed to match the new issues of sedation.
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Perioperative transfusion thresholds in the neurosurgical patient are undefined. Many neurosurgical procedures are associated with significant risk of bleeding. This review will summarize the current understanding of blood transfusion in the neurosurgical patient, as well as other blood component therapies and blood conservation strategies. ⋯ Perioperative transfusion management for intracranial neurosurgical procedures presents the clinician with multiple challenges. Clinical evidence is sparse with view to an optimal hemoglobin level, yet anemia is known to be a predictor of poor outcome in many neurosurgical patients. Transfusion thresholds from other patient populations may not apply to this group and further prospective investigations are desperately needed. Until then, clinicians should focus on an individualized assessment of anemia tolerance, consider blood conservation strategies and understand the potential risks and benefits of blood transfusion.