Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2007
ReviewManagement of patients with cardiac stents undergoing noncardiac surgery.
Coronary stenting is performed in over 4 million patients annually. Approximately 5% of these patients undergo a noncardiac surgical procedure within 1 year after stenting. Surgery might induce hypercoagulability. This causes increased concern about the effects of previous coronary stenting on postoperative cardiac outcome, particularly in-stent thrombosis. On the other hand, patients with multiple cardiac risk factors are at high risk for postoperative adverse cardiac events and might even benefit from preoperative prophylactic coronary revascularization. ⋯ Early noncardiac surgery after coronary stenting increases the risk of postoperative cardiac events. Interruption of antiplatelet therapy seems to play an important role in this increased event rate. Prophylactic coronary revascularization in cardiac stable, but high-risk patients does not seem to improve outcome.
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Curr Opin Anaesthesiol · Jun 2007
ReviewThe pediatric cardiac patient presenting for noncardiac surgery.
To summarize results of recent papers and discuss current trends concerning anesthesia in children with congenital heart disease presenting for noncardiac surgery. ⋯ Careful preoperative evaluation, experienced anesthesiologists, suitable anesthetic agents and techniques, and the liberal use of invasive monitoring are integral parts of safe and effective anesthetic care in children with congenital heart disease. Future studies have to show whether laparoscopic surgery may be beneficial in this special subgroup of patients.
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Anesthesia care for patients undergoing ambulatory gynecologic surgery has improved incrementally over the past few years. Emphasis has evolved beyond the safe provision of care, because this has largely been achieved. Comfort, speed, and efficiency have taken on new importance. ⋯ Local anesthetic use in gynecologic laparoscopy appears to improve postoperative pain control modestly, especially when given into the peritoneal cavity. Supralaryngeal airways, such as ProSeal LMA, appear to provide effective ventilation in laparoscopy, although their ability to protect against aspiration is unclear. The speed and comfort of emergence, recovery, and discharge may be improved by consciousness monitoring during general anesthesia and by drugs intended to modulate hemodynamics.
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To present the most recent publications on inhaled agents in children and their implications for clinical care. ⋯ Sevoflurane and desflurane continue to challenge our abilities to anesthetize children safely and efficiently. Although transient emergence delirium after insoluble agents is a problem, several medications may be used to attenuate it. Inhaled agents must be used with caution in children with Duchenne's muscular dystrophy as hyperkalemia may occur in young males and myocardial depression in adolescents. Rapid recovery after desflurane and single-breath inductions with sevoflurane continue to fascinate clinicians.
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This article reviews the challenging practice of systemic analgesia as an alternative to epidural analgesia for labor pain, and places remifentanil within the context of opioid analgesics suitable for managing for labor pain. ⋯ Remifentanil is now gaining popularity. Remifentanil may be more suitable than other traditional opioids for inducing labor analgesia. Careful monitoring of the parturient and the newborn is recommended, however, to mitigate the potential for maternal and neonatal hypoxemia.