Best practice & research. Clinical anaesthesiology
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Postdural puncture headache (PDPH) may develop after an unintended (accidental) dural puncture, after deliberate dural puncture for spinal anaesthesia or during diagnostic dural punctures performed by other medical specialties. PDPH may sometimes be predictable (patient characteristics, inexperienced operator or co-morbidities), is almost never immediately evident during the procedure, and sometimes presents late, after discharge. ⋯ Failure of EBP after the first attempt is not uncommon, and major complications may occur but are rare. In the current review of the literature, we discuss the pathophysiology, diagnosis, prevention and management of PDPH following accidental or intended dural puncture, and present possible therapeutic options for the future.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewSpinal anaesthesia in children: A narrative review.
Spinal anaesthesia is an established and frequently used anaesthetic technique in adults. However, this versatile regional anaesthetic technique is less frequently used in paediatric anaesthesia even though it can be used for minor (e.g. inguinal hernia repair) and major (e.g. cardiac surgery) surgical procedures. The aim of this narrative review was to summarize the current literature with regard to technical aspects, surgical context, choice of drugs, potential complications, as well as the effects of the neuroendocrine surgical stress response and potential long-term effects of anaesthesia during infancy. In summary, spinal anaesthesia represents a valid alternative in the paediatric anaesthesia setting also.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewNeuraxial drug delivery in pain management: An overview of past, present, and future.
Activation of neuraxial nociceptive linkages leads to a high level of encoding of the message that is transmitted to the brain and that can initiate a pain state with its attendant emotive covariates. As we review here, the encoding of this message is subject to a profound regulation by pharmacological targeting of dorsal root ganglion and dorsal horn systems. ⋯ Further developments are called for in delivery devices to enhance local distribution and to minimize concentration gradients, as frequently occurs with the poorly mixed intrathecal space. The field has advanced remarkably since the mid-1970s, but these advances must always address the issues of safety and tolerability of neuraxial therapy.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewCurrent status of the combined spinal-epidural technique in obstetrics and surgery.
Epidural and spinal blocks are well-accepted neuraxial techniques but both have several disadvantages. Combined spinal-epidural (CSE) can combine the best features of both techniques and reduce or eliminate these disadvantages. It provides the rapidity, density, and reliability of subarachnoid block with the flexibility of catheter epidural technique to extend the duration of anesthesia/analgesia (and to improve spinal block). ⋯ CSE is also used for cesarean delivery. The main purpose is to decrease the spinal dose so that spinal-induced hypotension can be reduced. However, reducing the spinal dose requires an epidural catheter to avoid intra-operative pain when surgery is prolonged.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewManagement of adverse effects of intrathecal opioids in acute pain.
Intrathecal opioids have been used for several decades in different clinical settings. They are easy to administer and provide many benefits in clinical practice, such as better quality of spinal anaesthesia, prolonged postoperative analgesia, decreased postoperative analgesic requirements and early mobilisation. ⋯ In contrast, intrathecal hydrophilic opioids may have potentially serious adverse effects, the most feared of which is respiratory depression. In this review, we will focus on the contemporary evidence regarding intrathecal hydrophilic opioids and present their adverse effects and how to manage them.