Best practice & research. Clinical anaesthesiology
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Spinal anaesthesia for spinal surgery is becoming increasingly more popular because this anaesthetic technique allows the patient to self-position and avoid neurological injury that may occur with prone positioning under general anaesthesia. Spinal anaesthesia reduces intraoperative surgical blood loss, improves perioperative haemodynamic stability and reduces pain in the immediate postoperative period. ⋯ These benefits increase the patient's satisfaction, and they expedite discharge of the patient from the hospital. Combination anaesthetic techniques, using both subarachnoid and epidural dosing schemes, may be beneficial for improving postoperative pain control and add further to the benefit of spinal anaesthesia for lumbar spine surgical procedures.
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Best Pract Res Clin Anaesthesiol · Sep 2003
Review Comparative StudySpinal anaesthesia and the use of anticoagulants.
This chapter addresses the increasing incidence of spinal haematoma after central neuraxis anaesthesia in patients receiving drugs that affect coagulation. Administration of low-molecular-weight heparins in the perioperative period is highlighted because these drugs remain the 'gold standard' for prophylaxis against deep-vein thrombosis. ⋯ In addition, issues such as those concerning the administration of unfractionated heparin, anti-vitamin K drugs or new antiplatelet and antithrombotic medications are addressed. Finally, specific recommendations regarding each class of drug are defined in order to avoid the occurrence of a rare but catastrophic event such as spinal haematoma.
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Best Pract Res Clin Anaesthesiol · Sep 2003
ReviewPost-dural puncture headache: pathophysiology, prevention and treatment.
Post-dural puncture headache (PDPHA) has been a vexing problem for patients undergoing dural puncture for spinal anaesthesia, as a complication of epidural anaesthesia, and after diagnostic lumbar puncture since Bier reported the first case in 1898. This Chapter discusses the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural spaces. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPHA than traditional cutting point needle tips (Quincke-point needles). ⋯ In high-risk patients (e.g. age < 50 years, post-partum, large-gauge-needle puncture), patients should be offered early (within 24-48 h of dural puncture) epidural blood patch. The optimum volume of blood has been shown to be 12-20 ml for adult patients. Complications of autologous epidural blood patch are rare.
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Best Pract Res Clin Anaesthesiol · Sep 2003
Review Comparative StudyContinuous spinal anaesthesia: what's new and what's not.
Continuous spinal anaesthesia combines the advantages of single-dose spinal anaesthesia, rapid onset and a high degree of success, with those of a continuous technique. The introduction of micro-catheters invigorated interest in the technique and allowed its expansion to additional populations and surgical procedures. ⋯ From this perspective, continuous spinal anaesthesia remains a useful and safe technique. Future research should focus on the comparison of continuous spinal anaesthesia with the combined spinal/epidural technique and the use of newer spinal agents.
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In the treatment of chronic benign pain, the administration of an intrathecal opioid produces a potent analgesia without interfering with the motor and sensory functions of the lower extremities. An intrathecal opioid should be considered only when pain control with conventional oral and systemic administration is inadequate or is associated with unmanageable side effects. A trial period and a psychological evaluation are mandatory prior to implantation of a permanent device. ⋯ Catheter granulomas can form with high concentrations of morphine. Adjuvant drugs such as bupivacaine, clonidine and ketamine might be necessary to deal with the development of tolerance to morphine. The sophistication of available technology for intrathecal infusion today far exceeds our knowledge of the potential neurological effects of this treatment modality.