Minerva anestesiologica
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Minerva anestesiologica · May 2003
Review Comparative StudyPost-operative epidural versus intravenous patient-controlled analgesia.
Patient-controlled analgesia techniques have opened a new dimension to individualize patient's need for analgesia, in the treatment of acute post-operative pain. These techniques can be used intravenously, in the epidural space, and into peripheral nerve sheets. There is a common consensus that intravenous patient-controlled analgesia should not have a continuous infusion while epidural patient-controlled analgesia (PCEA) should be programmed with a continuous infusion. ⋯ The continuous epidural infusion of opioids has the advantages of fewer fluctuations in cerebrospinal fluid concentrations of drug, but it is necessary to administer a loading bolus, to overcome the fact that it takes several hours to provide adequate analgesia. The advantages of epidural versus intravenous patient-controlled analgesia are represented by better analgesia and a reduced opioids requirement, while the advantages when compared to epidural continuous infusion are: increased efficiency, self-adjustment by the patient, higher patient satisfaction, less sedation, and lower opioids dosage. The clinical advantages of PCEA may outweigh the greater cost and invasiveness of this technique.
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Minerva anestesiologica · May 2003
Review[Prevention of hypotension in spinal anaesthesia carried out for caesarean section].
After describing the most commonly applied obstetric indications for caesarean section and the respective percentages reported in countries that are comparable with Italy in terms of health care standards, the clinical reasons and requirements on the basis of which it is considered that spinal anaesthesia is first choice compared to general anaesthesia in obstetrical surgery are outlined. This evidence is confirmed by the spinal anaesthesia/general anaesthesia ratio encountered in the major national and international Obstetric Hospitals. Maternal hypotension remains the most frequent and clinically important complication consequent on spinal anaesthesia in pregnant women at term. ⋯ It is pointed out that certain procedures have become part of standard practice but their effectiveness has not yet been confirmed while others are not only ineffective but also expose mother and foetus to potential complications. For others again the jury is still out on their real effectiveness. Finally, the techniques that are currently considered to be effective and shared by the majority of authors are described and these must therefore be included in the procedural protocols regarding spinal anaesthesia for caesarean section.
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Minerva anestesiologica · May 2003
Review[Anesthesia for neurosurgery in children: techniques and monitoring].
Pediatric neuroanesthesia can be seen as a specific branch of anesthesia half way in between pediatric anesthesia and neuroanesthesia. As a matter of fact, we must keep well in mind the peculiarities of the pediatric patient and the different pharmadynamic and pharmacochinetic properties of the anesthetic drugs, particularly in neonates and infants. Other relevant problems are: 1) high complexity of surgical procedures implying a difficult anesthesiological management; 2) complex blood loss management either if we want to apply a blood sparing technique strategy or if we consider the problems related to diagnosis and treatment of coagulative disorders caused by intraoperative massive blood loss; 3) management of patients with latex allergy for the high incidence, in pediatric neuroanesthesia, of patients belonging to high risk groups; 4) need of repeated radiological examinations implying several anesthesiological procedures. In this article aspects related to the anesthesiological techniques and to the hemodynamic and neurophysiological monitoring of pediatric neurosurgical patients were also discussed.
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Minerva anestesiologica · May 2003
ReviewUpper respiratory tract infections and pediatric anesthesia.
Anesthesia for the child with an upper respiratory infection (URI) presents a challenge for the pediatric anesthesiologist. Differences in study design have made interpretation and comparison very difficult. ⋯ More recent research, however, suggests that children with uncomplicated infections can undergo elective procedures without significant increase in adverse anesthetic outcomes. This presentation summarizes the evolving literature about cancellation of surgery for the child with an upper respiratory infection, perioperative outcomes and anesthetic management.
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The aim of the paper is to review the literature concerning 4 unanswered or debatable questions concerning the practice of regional anesthesia in pediatric patients. The published material concerning the 4 selected topics is reviewed, namely importance of ropivacaine, preoperative coagulation screening tests, hemodynamic stability following neuraxial blocks and prevention/treatment of post-dural puncture headache. Of the 4 questions considered in this article, 3 can be reasonably answered in a consensual way. ⋯ Preoperative coagulation screening tests are not necessary, even not useful in children when clinical history is not suggestive of coagulation disorders, with the notable exception of neonates and prematurely born infants less than 45 weeks of post-conceptual age. The long established hemodynamic stability following neuraxial blocks results from well equilibrated compensatory mechanisms which may not be functional in children with preoperative hemodynamic instability or anomalies of the regional blood flow distribution. Finally, even though the post-dural puncture headache is not frequent in children, its management still remains difficult and no definitive recommendation can be currently made in case of inadvertent dural puncture during an attempted epidural anesthesia in children.