International anesthesiology clinics
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Intrathecal opioids and the combined spinal/epidural technique provide new tools for the obstetrical anesthesiologist. With intrathecal opioids, we can rapidly and safely relieve the pain of labor without maternal sedation or motor blockade. Intrathecal sufentanil 10 micrograms provides 1 to 2 hours of excellent analgesia during the first stage of labor. ⋯ Unless morphine is used, the side effects induced by intrathecal opioids are usually mild and easily treated. In our practice, combined spinal/epidural labor analgesia has rapidly gained wide acceptance by patients, nurses, obstetricians, and anesthesiologists. Continuous spinal analgesia, although theoretically appealing, requires further refinement.
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General anesthesia is the most common form of anesthetic management for ambulatory surgery. Patients, in general, prefer general anesthesia because it is less anxiety provoking. During the last decade, the availability of several short-acting agents with high clearance has made general anesthetic techniques much safer and more predictable for outpatients. ⋯ The introduction of several new agents (e.g., propofol, desflurane, vecuronium, atracurium, mivacurium, rocuronium, alfentanil, ondansetron, ketorolac) has made ambulatory general anesthesia less challenging and more interesting. In the future, the new anesthetic sevoflurane, and the new opioid remifentanil, may prove useful for ambulatory anesthesia. The LMA has all but revolutionized airway management during general anesthesia for ambulatory surgery.
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Ambulatory anesthesia has become recognized as an anesthetic subspecialty, with formal postgraduate training programs. With increasing clinical experience, it is possible to determine which patients will derive the greatest clinical benefit from ambulatory surgery. Further expansion of the specialty of ambulatory anesthesia and surgery is likely to occur in the near future. ⋯ Increasingly, anesthesia practitioners as well as pharmacy and therapeutic committees are demanding evidence that new drugs and medical devices are superior to existing products--that they work better, have fewer adverse effects, and enhance efficiency, thereby reducing healthcare costs. As new biomedical technology is introduced to facilitate the perioperative management of patients (e.g., computerized anesthesia information management systems), evidence that these systems enhance our ability to provide high-quality, cost-effective health care will assume greater importance. The challenge that all practitioners face is to provide high-quality ambulatory anesthesia care at a reduced cost.
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Int Anesthesiol Clin · Jan 1994
ReviewBlood, fluids, and electrolytes in the pediatric trauma patient.
Successful resuscitation of pediatric trauma patients begins with identification of the physiological abnormalities that require intervention. Health care practitioners in the prehospital, emergency room, and operating room settings must be familiar with normal physiological parameters to be able to recognize abnormalities and begin resuscitative efforts. Recognition of shock may be more subtle in the pediatric patient, because blood pressure can be maintained in the face of a marked decrease in circulating blood volume. ⋯ The area of fluid management and blood transfusion has undergone extensive change in the last decade but needs continued investigation in the pediatric trauma population. Studies targeting this population are limited, and current practices are based largely on extrapolation from adult experience and studies. The area continues to evolve, but further research is needed to improve resuscitation in the pediatric trauma patient.
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Inadequately treated pain is a major cause of unanticipated hospital admissions after ambulatory surgery. The ability to provide adequate pain relief by simple methods that are readily available to the day-care patient in his or her home environment is one of the major challenges for providers of ambulatory surgery and anesthesia. The increasing number of extensive and painful surgical procedures (e.g., laparoscopic cholecystectomy, laminectomy, knee construction, hysterectomies) being undertaken on an ambulatory basis presents new challenges with respect to acute postoperative pain. ⋯ The aim of an analgesic technique should be not only to lower the pain scores but also to facilitate earlier mobilization and reduce perioperative complications. If future clinical investigations clarify the issues that have been raised by laboratory studies, clinicians may be able to effectively treat postoperative pain using combinations of "balanced," "preemptive," and "peripheral" analgesia. More important, improved analgesic techniques will increase patient satisfaction and enhance their perception of ambulatory anesthesia and surgery.