Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Jan 2010
Practice GuidelineRegional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).
The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). ⋯ As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.
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Reg Anesth Pain Med · Jan 2010
The effect of levosimendan on bupivacaine-induced severe myocardial depression in anesthetized pigs.
Levosimendan, an inodilator without proarrhythmogenic properties, has been shown to reverse ropivacaine-induced negative inotropy in isolated heart preparations. In this randomized and blinded study, we investigated whether levosimendan is able to reverse rapidly bupivacaine-induced myocardial depression in pigs. ⋯ Levosimendan together with the infusion of Ringer's solution rapidly reversed the cardiac depression, but there was no difference in overall cardiovascular recovery in comparison to treatment with Ringer's solution alone. Levosimendan-induced increase in heart rate possibly facilitated the recovery from bupivacaine intoxication.
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Reg Anesth Pain Med · Jan 2010
Modeling cost of ultrasound versus nerve stimulator guidance for nerve blocks with sensitivity analysis.
Ultrasound guidance for regional anesthesia has increased in popularity. However, the cost of ultrasound versus nerve stimulator guidance is controversial, as multiple and varying cost inputs are involved. Sensitivity analysis allows modeling of different scenarios and determination of the relative importance of each cost input for a given scenario. ⋯ If revenue is generated, then ultrasound-guided blocks consistently become a profit center regardless of clinical scenario in our model. Without revenue, the clinical scenario dictates the cost of ultrasound. In an ambulatory setting, ultrasound is highly competitive with nerve stimulator and requires at least a 96% success rate with nerve stimulator before becoming more expensive. In a hospitalized scenario, ultrasound is consistently more expensive as the uniform use of general anesthesia and hospitalization negate any positive cost effects from greater efficiency with ultrasound.