Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewDifferent protocols used today to achieve total opioid-free general anesthesia without locoregional blocks.
With increasing awareness of both short- and long-term problems associated with liberal perioperative opioid administration, the need for routinely and clinically feasible alternatives is greater than ever. Opioid-free anesthesia-previously reserved for bariatric surgery-is receiving increasing attention in mainstream anesthesia. ⋯ For a concrete clinical perspective, we present in depth our opioid-free protocol for bariatric surgery. However, clinicians must be aware of potential problems related to opioid-free anesthesia.
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewSpecial indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery.
Opioid-free anaesthesia (OFA) is a technique where no intraoperative systemic, neuraxial or intracavitary opioid is administered with the anaesthetic. Opioid-free analgesia similarly avoids opioids in the perioperative period. There are many compelling reasons to avoid opioids in the surgical population. ⋯ Non-opioid adjuvants such as NSAIDS, paracetamol, magnesium, local anaesthetic infiltration and high-dose steroids are added in the perioperative period to further achieve co-analgesia. Loco-regional anaesthesia and analgesia are also maximised. It remains to be seen whether OFA and early postoperative analgesia, which similarly avoids opioids, can prevent the development of hyperalgesia and persistent postoperative pain syndromes.
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Lidocaine has analgesic effect and antihyperalgesic and anti-inflammatory properties, which enable its use as a general anesthetic adjuvant. Lidocaine can reduce nociception and/or cardiovascular responses to surgical stress, postoperative pain, and/or analgesic requirements. However, its mechanisms of action remain unclear, despite its different known properties. ⋯ It clearly improves the postoperative outcomes with increased patient satisfaction. Such procedures should be included wisely in the enhanced recovery after surgery protocols. By using the recommended protocols, a high safety and efficacy of lidocaine can be achieved.
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Today, up to 20% of all intensive care unit patients require renal replacement therapy (RRT), and continuous renal replacement therapies (CRRT) are the preferred technique. In CRRT, effective anticoagulation of the extracorporeal circuit is mandatory to prevent clotting of the circuit or filter and to maintain filter performance. At present, a variety of systemic and regional anticoagulation modes for CRRT are available. ⋯ Compared to systemic anticoagulation, RCA prolongs filter running times, reduces bleeding complications, allows effective control of acid-base status, and reduces adverse events like HIT-II. In this review, we will discuss systemic and regional anticoagulation techniques for CRRT including anticoagulation for patients with HIT-II. Today, RCA can be recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.