Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2005
ReviewNerve stimulation in regional anesthesia: theory and practice.
There is now an accumulation of extensive and varied experience with the use of electrical stimulation for verifying the close approximation of needle and nerve, and for increasing the corresponding success rate. The application of this experience has been of proven benefit in the teaching of regional anesthetic techniques, in the performing of difficult nerve blocks, and in the use of novel accesses, resulting in decreased morbidity and a reduced requirement for local anesthetic. ⋯ Sound knowledge of the anatomy of the area to be blocked, the muscle territory subsidiary to the nerve in question, the applied neurophysiology, and the pharmacology of the local anesthetic used are needed. This chapter reviews the most important aspects, from nerve anatomy and physiology, to electrical features of the needle, and devices used for the updated clinical application of nerve stimulation in the practice of plexus regional anesthesia.
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In recent years, regional anaesthesia in children has generated increasing interest. Continuous peripheral nerve blocks have an important role in the anaesthetic arsenal, allowing effective, safe and prolonged postoperative pain management. Indications for continuous peripheral nerve blocks depend on benefits/risks analysis of each technique for each patient. ⋯ New techniques, such as transcutaneous stimulation or ultrasound guidance, appear to facilitate nerve and plexus identification in paediatric patients. Nevertheless, continuous peripheral nerve block may mask compartment syndrome in certain surgical procedure or trauma. Finally, ropivacaine appears to be the best local anaesthetic for continuous peripheral nerve blocks in children, requiring low flow rate with low concentration of the local anaesthetic.
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Best Pract Res Clin Anaesthesiol · Jun 2005
ReviewUltrasonography in the current practice of regional anaesthesia.
Ultrasound imaging techniques in regional anaesthesia are becoming a subject of major interest. The quality of blocks and analgesia is relevant to the perioperative outcome of patients and the development of perfect blocks has always been a focus in regional anaesthesia research. ⋯ A second advantage is that the puncture process and the application of medication can be demonstrated and clearly observed during the performance. If there is a problem with the spread or the application, the processing of the block can be immediately modified to improve the quality of the technique.
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Thoracic epidural analgesia (TEA) provides optimal perioperative anaesthesia and analgesia after thoracic and major abdominal surgery and decreases postoperative morbidity and mortality, mainly by blocking sympathetic nerve fibres. Surgery leads to a stress response characterized by sympathetic arousal, altered balance of catabolic and anabolic hormones, hypermetabolism, negative protein economy, and altered carbohydrate metabolism and immune function. A threefold increase of the plasma level of norepinephrine (noradrenaline) was detected up to 24 hours after surgery. ⋯ Optimized pain control and early mobilization decrease the riskof pulmonary complications, resulting in a shortened stay in intensive care units. In combination with early enteral nutrition, TEA leads to an earlier return of gastrointestinal function. Patients treated with thoracic epidural anaesthesia and analgesia have a better health-related quality of life.
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Although retrobulbar and peribulbar regional anaesthetic techniques are used (by both anaesthesiologists and ophthalmologists) in various types of eye surgery, topical anaesthesia of the conjunctiva and cornea, followed--as needed--by sub-Tenon's block, is now common in routine cataract surgery. Intracameral administration of local anaesthetic by the ophthalmologist is also performed. Sedation during ophthalmic surgery is distinctly lighter than for other surgery because it is essential that the patient remains alert and can cooperate with the surgeon. ⋯ With a catheter placed into the nostril, the patient (whose head is draped and 'hidden') can have the end-tidal CO2 monitored. Finger index (FI), a palpation method that assesses the ease of performing retrobulbar block, is introduced. Because of the risk of life-threatening complications in ophthalmic regional anaesthesia, the services of an anaesthesiologist must be available and training of anaesthesia residents in ophthalmic regional anaesthesia is highly recommended.