AANA journal
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Concussions affect the normal functioning of the autonomic nervous system and glucose metabolism, impair cerebral autoregulation to Paco₂, and produce abnormal variances in myogenic and vagal tone. Because anesthesia also has an impact on these same processes, it is vital to delineate the best practice in the perianesthesia period to minimize additional damage to the concussed brain. There are currently no practice guidelines surrounding perianesthesia management of patients with concussion to guide practice. ⋯ The impact of particular anesthetic agents on concussion injuries is unknown. Major advances in neuroimaging, biomarker identification, and technology have occurred. However, further research is needed to identify evidence-based interventions for managing patients after concussion requiring anesthesia.
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The Institute of Medicine has reported that greater than 115 million adults in the United States are living with some form of chronic pain. Back pain is the most prevalent and is associated with high individual morbidity and increased healthcare costs. One approach for the management of chronic back pain involves the injection of corticosteroids in the epidural space. ⋯ Epidural steroid injections are considered safe and effective, and are supported by evidence for the treatment of radicular pain. Complications from epidural steroid injections are rare but can be catastrophic, including permanent disability and death. The focus of this article is to understand how technique and selection of specific corticosteroids used for epidural injection can manage chronic back and radicular pain effectively while minimizing risk that leads to unnecessary harm.
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The term vasoplegia describes hypotension refractory to vasopressor therapy, a common finding related to cardiac surgery requiring cardiopulmonary bypass. High doses of vasoactive agents are associated with adverse effects such as peripheral and mesenteric ischemia. Databases were systematically searched for literature on methylene blue as an adjunct therapy to treat vasoplegia. ⋯ Its favorable safety profile as well as hemodynamic effects have made methylene blue a valuable adjunct in the setting of vasoplegia. Methylene blue is an effective treatment of refractory hypotension related to cardiac surgery requiring cardiopulmonary bypass. Larger, randomized controlled trials are needed to strengthen the state of the evidence and to define specific doses.
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Lowering the dose of the local anesthesia significantly reduces the risks of spinal anesthesia-induced hypotension in an elective cesarean delivery. Determination of the mean effective dose of hyperbaric bupivacaine will aid clinicians in managing maternal hypotension. The systematic search of studies evaluating the mean effective dose of hyperbaric bupivacaine yielded 10 clinical trials reporting the minimum effective dose in 50% (ED50) and 95% (ED95) of patients. ⋯ Doses at the level of ED50 minimized spinal anesthesia-induced hypotension yet increased intraoperative pain supplementation, whereas doses at the level of ED95 provided adequate surgical anesthesia with increased risk of maternal hypotension. Furthermore, the addition of intrathecal administration of opioids reduced local anesthetic doses. In the clinical setting, low-dose spinal anesthesia should be used only in combination with the combined spinal-epidural technique.
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Hypotension and bradycardia are common adverse effects following spinal anesthesia. Ondansetron has been studied in the attenuation of spinal anesthesia– induced hypotension (SIH) and bradycardia because of its antagonistic effect on the Bezold-Jarisch reflex. The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to determine the efficacy of intravenous (IV) ondansetron in reducing the incidence of SIH and bradycardia. ⋯ Heterogeneity was summarized using randomeffects model for I(2) greater than 50%; otherwise, a fixed-effects model was performed. Intravenous ondansetron reduced the incidence of hypotension in both the all-procedure analysis group (RR, 0.64; CI, 0.45-0.90) and cesarean delivery group (RR, 0.63; CI, 0.45-0.88). For bradycardia, IV ondansetron resulted in reduced risk (RR, 0.31; CI, 0.19-0.50). Findings of our meta-analysis suggest that IV ondansetron may mitigate the risks of SIH and bradycardia following spinal anesthesia.