Current opinion in anaesthesiology
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To review the techniques for imaging cerebral blood flow and metabolism following injury to the brain. ⋯ Imaging of cerebral blood flow and metabolism has been shown to be useful following a variety of causes of brain injury, as it can help to define the cause and extent of injury, identify appropriate treatments and predict outcome. Imaging based on CT techniques (Xenon CT and CT perfusion) can be implemented easily in most hospital centres, and are able to provide quantitative perfusion data in addition to structural images.
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Patients at risk for perioperative stroke, or those who have suffered recent cerebral injury, may benefit from neuroprotective properties of anesthetic agents during surgery. This manuscript reviews recent clinical and experimental evidence for neuroprotective effects of common anesthetic agents, and presents potential mechanisms involved in anesthetic neuroprotection. ⋯ Solid experimental evidence supports neuroprotection by anesthetic agents. It is too early to recommend any specific agent for clinical use as a neuroprotectant, however. Further study is warranted to unravel relevant mechanisms and to appreciate the potential clinical relevance of experimental findings.
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Incisional pain remains underevaluated and undermanaged while evidence is growing that perioperative treatments strongly influence patients' outcome. The present review examines the recent developments in mechanisms underlying perioperative pain and questions current understanding of incisional pain features observed in patients. ⋯ Experimental studies and recent clinical trials using objective measures of sensory processing sensitization induced by surgical incision have shown the importance of hyperalgesia in perioperative pain. Effective perioperative block of nociceptive inputs from the wound as well as use of antihyperalgesic and analgesic drugs in combination seem the best way to control postoperative pain and specifically to prevent central sensitization.
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The ongoing debate on the outcome benefits of regional anaesthesia and analgesia over general anaesthesia and systemic analgesia has led to a large number of recently published papers, in particular systematic reviews and meta-analyses that justify a review of the current status of the debate. ⋯ Although there are a considerable number of recent publications on the topic, the complex issues around the effect of regional anaesthesia on outcome is not completely resolved, possibly because the data are often not procedure specific. In addition, however, it may be that our current literature cannot provide a definitive answer.
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Clinicians are actively looking for an effective brain protection technique. With pharmacologic agents, several phase III trials in stroke, severe traumatic brain injury, and post-cardiac arrest survivors have failed. Hence there is renewed interest in mild to moderate hypothermia for brain protection. Phase III clinical trials with hypothermia have been successful only in post-cardiac arrest survivors and neonatal hypoxic encephalopathy. This review focuses on the possible reasons for our inability to translate into positive clinical trials what is observed consistently in laboratory models. ⋯ Hypothermia can at present be recommended only for post-cardiac arrest survivors and in neonatal hypoxic encephalopathy.