Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMaking an ambulatory surgery centre suitable for regional anaesthesia.
This chapter reviews a management strategy for transforming an outpatient surgery centre from that which exclusively uses general anaesthesia to one using regional anaesthesia with peripheral nerve blocks. Barriers presented by patients, nursing staff, surgeons and administrators can be notable; these might undermine the well-intended efforts of highly-skilled regionalists. ⋯ The centerpiece of the anaesthesia care process remains pre-emptive multimodal analgesia, routine multimodal antiemetic prophylaxis and avoidance of general anaesthesia (GA) with volatile agents. The remainder of the care process relies on teamwork among all healthcare providers and meaningful administrative support.
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The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. ⋯ This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.
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Best Pract Res Clin Anaesthesiol · Mar 2002
ReviewAnaesthesia for minimally invasive surgery in children.
There continues to be an increase in the applications of minimally invasive surgical techniques in infants and children. This increase includes their use for new surgical procedures as well as their application in younger patients including neonates. As with any new surgical procedure, specific modifications of the anaesthetic technique may be necessary. This chapter reviews (1) the pre-operative evaluation of infants and children scheduled for minimally invasive surgery; (2) techniques for pre-medication and anaesthetic induction; (3) intra-operative anaesthetic implications of laparoscopy, including the cardiorespiratory consequences of CO2 pneumoperitoneum; (4) intra-operative anaesthetic implications of thoracoscopy, including techniques for one-lung ventilation (OLV); and (5) post-operative issues, including pain management and monitoring of cardiorespiratory function as they apply to the patient of paediatric age.
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Technological advances in imaging, computing and surgical instrumentation have encouraged the application of minimally invasive surgical techniques to various neurosurgical disorders. This chapter discusses the wide application of neurosurgery and the implications for anaesthesia, focusing on the specific anaesthetic considerations for neuroendoscopy, stereotactic procedures and radiosurgery.
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Best Pract Res Clin Anaesthesiol · Mar 2002
ReviewAnaesthesia for minimally invasive gastric and bowel surgery.
It is of great importance that anaesthetic regimens match surgical procedures in regard to surgical time, in reducing organ dysfunction elicited by the anaesthesia and surgical trauma and by providing optimal post-operative pain treatment, leaving the possibility of early mobilization. New, rapidly eliminated anaesthetic drugs are, by virtue of their pharmacodynamic and pharmacokinetic profiles, optimal for use; combined with continuous thoracic epidurals with local anaesthetics and low-dose opioids, these drugs may permit reduction of various post-operative complications. ⋯ Few studies have evaluated whether these changes affect surgical outcome and whether or not different anaesthetic regimens influence relevant morbidity parameters. In future documentation it is important that controlled, well-designed clinical studies evaluate how the advantages from multimodal anaesthetic techniques improve relevant surgical outcome.