Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2013
ReviewReview article: Intrapartum neuraxial analgesia and breastfeeding outcomes: limitations of current knowledge.
Although numerous studies have addressed the relationship between intrapartum neuraxial analgesia, particularly epidural fentanyl, and breastfeeding, substantial study design limitations have precluded the current literature from furnishing strong, clinically significant conclusions. Lack of randomized controlled trials, nonstandardization of breastfeeding evaluations across studies, and failure to control for confounding variables all pose significant problems. Further research is needed to elucidate the specific relationship between neuraxial opioids and breastfeeding and, if there are significant associations, whether these drugs act directly on neonatal brain tissue to attenuate exhibition of breastfeeding behaviors. In this review, I will detail the deficiencies of the current literature and make recommendations for future research.
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Anesthesia and analgesia · Feb 2013
Review GuidelineReview article: Extubation of the difficult airway and extubation failure.
Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. ⋯ Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of postextubation airway compromise, and understanding the causes and underlying mechanisms of extubation failure. An effective strategy to minimize postextubation airway complications should include preemptive optimization of patients' conditions, careful timing of extubation, the presence of experienced personnel trained in advanced airway management, and the availability of the necessary equipment and appropriate postextubation monitoring.
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Anesthesia and analgesia · Feb 2013
Evaluation of central venous pressure monitoring in children undergoing craniofacial reconstruction surgery.
Massive hemorrhage during craniofacial surgery is common and often results in hypovolemia and hypotension. We conducted this study to assess the effect of the addition of routine central venous pressure (CVP) monitoring on the incidence of intraoperative hypotension and to evaluate the relationship between CVP and hypotension in this population. ⋯ The implementation of routine CVP monitoring was not associated with a decreased incidence and likely was not associated with a decreased duration of hypotension in this population experiencing massive hemorrhage. Hypotension was associated with a decrease in CVP, and resolution of hypotension was associated with an increase in CVP to prehypotensive levels. However, significant decreases in CVP below the baseline were common and usually not associated with hypotension. The routine use of CVP monitoring in these children is of questionable utility as a means to decrease the incidence and duration of hypotension.
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Anesthesia and analgesia · Feb 2013
Comparative StudyReal-time three-dimensional transesophageal echocardiography: improvements in intraoperative mitral valve imaging.
Successful surgical repair of a regurgitant mitral valve (MV) is dependent on a comprehensive assessment of its complex anatomy. Although there is limited evidence of the feasibility and accuracy of intraoperative real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in MV surgery, its use is increasing worldwide. We designed this prospective observational study of patients with mitral regurgitation to test initial findings on the accuracy of RT3DTEE images in the diagnosis of MV prolapse and chordal rupture relative to 2D imaging and to assess the potential of RT3DTEE for visualizing leaflet clefts. ⋯ Although 2D TEE is currently the standard tool for intraoperative imaging in MV surgery, RT3DTEE improves the visualization of MV pathology and increases the accuracy of interpretation by facilitating spatial orientation. Further investigations, particularly those aimed at establishing its cost effectiveness, are indicated.