Articles: general-anesthesia.
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Despite advances in the anesthetic pharmacopeia and improved noninvasive monitoring techniques, subjective bias and individual clinical experience remain major determinants of individual practice. Medicolegal pressures have increased in recent years, as has the concept of shared responsibility for surgical and anesthetic complications. New standards of anesthesia monitoring and practice are evolving in response to the need for perioperative risk management and cost-effective surgical care. Continued vigilance and close communication between the otolaryngologist and anesthesiologist remain key elements for safe anesthetic practice.
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The ideal neuromuscular blocking drug for dental and other outpatient procedures would be nondepolarizing (therefore reversible), highly potent, have a rapid onset and short duration of action, be highly specific for the nicotinic acetylcholine receptor, be eliminated independently of renal or hepatic metabolism, and have minimal side effects such as tachycardia and histamine release. The newer neuromuscular blocking drugs vecuronium and atracurium approach this ideal much more closely than the older drugs curare, metocurine, and gallamine. Aside from considerations of slightly higher cost, the neuromuscular blocking agents of choice remain succinylcholine for rapid, short-lived paralysis, vecuronium and atracurium for relaxation of 15- to 60-minute duration and when cardiovascular stability is vital, and pancuronium for longer surgical procedures. Vecuronium and atracurium have achieved and will continue to achieve predominance in the anesthetic management of the short-procedure patient.
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Adv Tech Stand Neurosurg · Jan 1987
Review Comparative StudyNeuro-anaesthesia: the present position.
Over the years the basic principles underlying the practice of neuroanaesthesia have not changed, but introduction of new anaesthetic agents and associated techniques have improved the ability of the neuroanaesthetist to "fine tune" the patients physiological state. This has improved the capacity of the neuroanaesthetist to mitigate the inevitable fluctuations which occur and prevent their ill effects. ⋯ It takes years for the correct plan of usage of new drugs to be formulated for the clinical situation, and their relationships established to new techniques of patient monitoring. Like neurosurgery itself neuroanaesthesia shows no signs of approaching a final definitive state in the forseeable future.
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Children with neurological and neuromuscular diseases often present anesthetic problems in the perioperative period. The anesthetic technique can play a significant role in altering the state of the brain during neurosurgical procedures through effects on the cerebral circulation and metabolism. Pre-existing neuromuscular disease may also have specific anesthetic implications such as cardiorespiratory involvement (eg, myotonia dystrophica), the potential for drug interactions (eg, myasthenia gravis) or abnormal responses to commonly used drugs (eg, malignant hyperthermia). In this review, the perioperative anesthetic considerations in a number of common neurological and neuromuscular conditions in the pediatric patient are discussed.