Best practice & research. Clinical anaesthesiology
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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
Review Comparative StudySpinal anaesthesia for obstetrics.
For a long time, epidural anaesthesia has been considered the method of choice for Caesarean delivery. The increased incidence of hypotension by the rapid onset of sympathetic blockade under spinal anaesthesia has been associated with a decline in uteroplacental blood flow and significant fetal acidosis, which may compromise neonatal well-being. Nevertheless, a decrease in fetal pH has not been shown to reduce neonatal Apgar or neurobehavioural assessment scores. ⋯ Spinal anaesthesia is now considered the method of choice for urgent Caesarean section. The use of intrathecal opioids has profoundly changed the quality of spinal anaesthesia, with improved analgesia, a reduction in local anaesthetic requirements and shorter duration of motor blockade. Preliminary studies indicate that spinal anaesthesia may be safely performed in patients with severe pre-eclampsia, in whom spinal anaesthesia was previously considered contraindicated.
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Best Pract Res Clin Anaesthesiol · Sep 2003
ReviewPhysiology of spinal anaesthesia and practical suggestions for successful spinal anaesthesia.
There are numerous physiological effects of spinal anaesthesia. This chapter focuses on the physiological effects that are of clinical relevance to the anaesthesiologist, and provides suggestions for successful management of this simple and popular technique. The mechanisms and clinical significance of spinal-anaesthesia-induced hypotension, bradycardia and cardiac arrest are reviewed. ⋯ The importance of thermoregulation during spinal anaesthesia, and the clinical consequences of spinal-anaesthesia-induced hypothermia are reviewed. Effects of spinal anaesthesia on ventilatory mechanics are also highlighted. Lastly, the sedative and minimum-alveolar-concentration-sparing effects of spinal anaesthesia are discussed to reinforce the need for the judicious use of sedation in the perioperative setting.
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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
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.