Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewSurgical site infiltration: A neuroanatomical approach.
Local anaesthetic administration into a surgical wound blocks the noxious stimuli that result from surgical insult at the site of origin. Surgical site infiltration (also known as local infiltration analgesia) is easy to perform, safe and inexpensive. In addition, it avoids motor blockade, which is particularly relevant for lower limb surgery. ⋯ Bupivacaine and ropivacaine are sometimes combined with additives, which have controversial benefits. Continuous wound infusion with preperitoneal wound catheters is an effective pain modality in abdominal surgery and can be used as an alternative for neuraxial analgesia. It is essential that surgical site infiltration is combined with other non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs to attain the maximum analgesic efficacy.
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewPain measurement and critical review of analgesic trials: pain scores, functional pain measurements, limits and bias of clinical trials.
Randomized clinical trials designed to assess analgesic agents and/or techniques used for postoperative pain control have several limitations, which are addressed in this article. Efficacy of analgesics cannot be limited to the evaluation of pain intensity or the amount of opioid rescue medication, but it also means to evaluate parameters such as the delay and duration of the effect, the number of patients with satisfactory pain control, and side effects. Because combination of analgesics is the standard of care in clinical practice, its value also needs to be documented. Eventually, analgesic treatments have to be considered in the settings of postoperative supportive care and enhanced recovery programmes after surgery.
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Best Pract Res Clin Anaesthesiol · Jun 2019
ReviewPredicting hypotension in perioperative and intensive care medicine.
Blood pressure is the main determinant of organ perfusion. Hypotension is common in patients having surgery and in critically ill patients. The severity and duration of hypotension are associated with hypoperfusion and organ dysfunction. ⋯ Hypotension can now be predicted minutes before it actually occurs from the blood pressure waveform using machine-learning algorithms that can be trained to detect subtle changes in cardiovascular dynamics preceding clinically apparent hypotension. However, analyzing the complex cardiovascular system is a challenge because cardiovascular physiology is highly interdependent, works within complicated networks, and is influenced by compensatory mechanisms. Improved hemodynamic data collection and integration will be a key to improve current models and develop new hypotension prediction models.
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Postoperative complications within 30 days represent the third leading cause of death in the world. Multiple solutions have been proposed to tackle the clinical and economic burden of postoperative complications. They include the optimal fluid and hemodynamic management of patients undergoing major surgery. ⋯ The monitoring of microcirculation and tissue perfusion may help to fine tune this approach. Importantly, mortality within 30 days after surgery is 1000 times higher than intraoperative mortality. Therefore, continuous ward monitoring with wireless and wearable sensors may be the next major opportunity to improve patient safety.