Current opinion in anaesthesiology
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Caudal epidural blockade remains the cornerstone of pediatric regional anesthesia. In this article we provide a comprehensive review of the recent developments in caudal anesthesia in infants and children. ⋯ The addition of ketamine or clonidine to a caudal local anesthetic prolong the duration of the block. However, a preservative-free preparation of ketamine that is suitable for neuraxial use is not widely available. Ultrasound imaging and electrical stimulation are promising options to accurately position a caudal needle. However, because ultrasound imaging is more difficult in older children, nerve stimulation is a more-suitable technique to accurately guide caudal catheters in this patient population. Although complications associated with caudal block are rare, the risks and benefits must be carefully considered on an individual basis.
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With the continuous development of technological advances for diagnosis and treatment comes the increased need for anesthesia outside of the operating room. Children, because of their inability to cooperate with lengthy imaging procedures or painful treatments, form the largest group needing non operating room anesthesia (NORA). As the distinction between deep sedation and general anesthesia becomes less clear, it has become increasingly common for institutions to dedicate resources for pediatric NORA (as opposed to sedation services) to improve predictability, comfort, and safety. ⋯ NORA is a specific microsystem environment that must integrate operating room systems with those of other departments and specialties. Often the children that require these procedures have chronic illnesses and return at frequent intervals with complex medical, psychological, and behavioral issues. Special knowledge, training, and support infrastructure are required to provide optimal care for these expanding services.
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Curr Opin Anaesthesiol · Jun 2005
Recent advances in patient-controlled epidural analgesia for labour.
Patient-controlled epidural analgesia (PCEA) is a relatively new mode of maintenance of labour analgesia. The purpose of this review is to demonstrate that PCEA has several advantages over continuous-infusion analgesia and to discuss recent refinements in the use of PCEA for labour. ⋯ PCEA has proven to be a safe, convenient, and highly effective way to maintain labour analgesia. Parturients appreciate the control they have over the analgesia received throughout labour when this method is used.
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To evaluate the relevance of new local anesthetics in pediatric regional anesthesia. ⋯ The goal of anesthetists using regional anesthesia is to use local anesthestics that are as safe and effective as possible, with a rapid onset and a long duration. Even though adequate dose guidelines are available, several toxic effects are reported with the use of bupivacaine in children due to inadvertent intravenous injection, long-term infusion (> 48 h) or administration in newborn babies and infants with reduced metabolism. Ropivacaine and levobupivacaine are new local anesthetics with a wider safety margin that have similar characteristics: both of them are pure S-(-)-enantiomers whose main pharmacological features are less cardio- and neuro-affinity and -toxicity in comparison with the racemic formulae and R-isomers, and a differential neural blockade with less motor than sensory block. Several clinical studies in children compare ropivacaine and levobupivacaine with bupivacaine.
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Curr Opin Anaesthesiol · Jun 2005
Current status and clinical relevance of studies of minimum local-anaesthetic concentration (MLAC).
Studies comparing the effects of epidural local anaesthetics have been limited by the lack of knowledge of their relative potencies. In 1995 the concept of the minimum local-anaesthetic concentration (MLAC) was introduced, this has been defined primarily as the median effective analgesic concentration in the first stage of labour. Pharmacologically, this model aims to determine equipotent analgesic concentrations of local anaesthetics, to compare motor effects and to evaluate the relative toxicity during labour. However, results of recent MLAC studies are not uniform and rather confusing, and thus, the basic validity of the MLAC concept for determining local-anaesthetic potency is increasingly discussed. ⋯ Relative differences in local anaesthetics' potencies derived from MLAC examinations are meaningful and correct from the pharmacological point of view, but they cannot simply be transferred to daily clinical practice. Thus, MLAC values should not be misinterpreted as these data are not suggested to be suitable to define and quantify the pharmacodynamics of local anaesthetics, nor to unequivocally predict their toxicological profile in clinically relevant concentrations.