Regional anesthesia
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Regional anesthesia · Nov 1996
Meta Analysis Comparative StudyComparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer.
Although rarely used, intracerebroventricular opioid therapy (ICV) is an option for the control of intractable pain due to cancer when systemic treatments have failed. The aim of the present study is to use available data from published trials to compare ICV with the more common epidural (EP) and subarachnoid (SA) opioid treatments in an attempt to establish the utility and safety of ICV. ⋯ Intracerebroventricular therapy appears to be at least as effective against pain as other neuraxial treatments. The ICV technique is the only fixed system that is associated with fewer technical problems than the use of simple percutaneous epidural catheters (difference 9%, standard error of the difference 3.4). The present state of evidence indicates that ICV is a successful treatment for patients with intractable cancer pain and compares well with spinal opioid treatments in terms of efficacy, side effects, and complications.
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Regional anesthesia · Nov 1996
ReviewEpidural opioid delivery methods: bolus, continuous infusion, and patient-controlled epidural analgesia.
Multiple methods of delivery of epidural opioids are acceptable, including bolus injection, continuous infusion, and patient-controlled infusion. The incidence of side effects appears to be reduced with the use of continuous infusion techniques, especially with the liquid-soluble opioids, although these appear to be most effective when infused near the center of the dermatomal pain site. with more distant catheters, the water-soluble opioids are more effective, but there use is associated with more frequent side effects. The lowest dose requirement appears to be associated with PCEA, but further study is needed to confirm the theoretical safety and efficacy of this modality, especially if a constant background infusion is used along with the PCEA. At present, significant advantages appear to be obtainable by adding local anesthetic to the opioid infusion, but the ideal drug and dosage are yet to be determined.
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The expanded role for antiplatelet drugs and anticoagulant therapy has resulted in more surgical patients receiving these medications during the perioperative period. The risk of developing a spinal hematoma (epidural, subdural, or subarachnoid) remains exceedingly small in most patients despite receiving these therapies. Despite the low incidence, potentially devastating neurologic sequelae often occur in the patient who develops a spinal hematoma. ⋯ It remains extremely important that practitioners continue to report the occurrence of such hematomas, so that information can be gleaned from their experience. The experience of practitioners with LMWH and central neuraxial block, described above, currently is providing us with important information, which may ultimately affect the way we practice. Without case reporting of this information, the knowledge would remain unobtainable.
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Regional anesthesia · Nov 1996
Case ReportsEssential thrombocythemia and epidural analgesia in the parturient. Does thromboelastography help?
It is often considered that essential thrombocythemia contraindicates placement of an epidural catheter because of the danger of epidural hematoma. Thromboelastography offers a possible means of determining the appropriateness of epidural analgesia in a patient with this disorder. ⋯ Thromboelastography may be a useful diagnostic test in determining the suitability of regional techniques for labor analgesia in parturients with essential thrombocythemia. However, success in one patient does not prove the general safety of this approach.