Anesthesia and analgesia
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Anesthesia and analgesia · Jul 2019
Comparative StudyComparative Effects of Sodium Bicarbonate and Intravenous Lipid Emulsions on Reversing Bupivacaine-Induced Electrophysiological Toxicity in a Porcine Experimental Model.
Bupivacaine cardiotoxicity mainly manifests as inhibition of the cardiac sodium channel, which slows conduction, particularly at the ventricular level. Experimental studies have demonstrated that intravenous lipid emulsions (ILEs) can reduce the cardiotoxic effects of bupivacaine, but the extent of these effects is controversial. Sodium bicarbonate (B) represents the standard treatment of toxicity related to sodium channel-blocking drugs. The aim of this study was to compare the effects of ILEs and B on the speed of recovery from bupivacaine-induced effects on the electrocardiographic parameters. ⋯ In a closed-chest swine model, B was an effective treatment for electrophysiological alterations caused by established bupivacaine toxicity. At clinical doses, B ameliorated bupivacaine electrocardiographic toxicity faster than ILE. Use-dependent effects of bupivacaine are prominent and delay the effects of both antidotes, but B produces faster recovery than ILE.
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Anesthesia and analgesia · Jul 2019
Meta AnalysisKetamine Infusions for Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Why?
Although often used to manage chronic pain acutely, the longer-term benefits of ketamine infusions remain uncertain. Despite this there has been significant growth in using ketamine infusions to treat chronic pain, rationalised by ketamine’s expected effect to reduce central sensitisation.
What?
This meta-analysis identified a small benefit for up to two weeks after a ketamine infusion, although little evidence of longer-term benefit. There appears to be a dose-response effect, suggesting greater efficacy with high-dose ketamine infusions.
The underlying problem...
Most research on ketamine infusions focuses on perioperative analgesia. Trials invetsigating ketamine infusions for chronic pain are universally small, lack standardisation and are often low quality.
This meta-analysis unfortunately does not add clarity to the question of whether ketamine infusions have long-term benefit in chronic pain syndromes. Clinicians will continue to need to judge indication on a case-by-case basis...
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Anesthesia and analgesia · Jul 2019
ReviewEvidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery.
Why is this important?
With obesity rates over 40% in many industrialised countries, and accelerating growth in bariatric surgery for more than a decade, there is need for evidence based guidelines to direct perioperative care.
This evidence review was conducted to identify protocols that achieve "superior outcomes, reduced length of hospital stay, and cost savings" for bariatric patients.
Many of the institutional protocols were founded on ERAS principals originating with colorectal surgery.
Ok, what did they identify?
The AHRQ made evidence-based anesthesia recommendations across three areas:
- Preoperative: reduce fasting; provide carbohydrate loading; multimodal preanesthesia medication.
- Intraoperative: standardised intraoperative anesthesia; protective ventilation; goal-directed fluid therapy (minimization); postop nausea and vomiting prophylaxis.
- Postoperative: multimodal analgesia.
Reality check
These protocols largely reflect 'good quality modern anesthesia', and there is little here that is specific to bariatric patients.
This is not a critcism, but a reminder that it's consistent and holistic application of quality anesthesia across the perioperative period that improves outcomes – especially among higher risk patients. Interventions do not need to be fancy, just quality principles consistently applied.
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Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. ⋯ This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.
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Anesthesia and analgesia · Jul 2019
Randomized Controlled TrialUltrasound-Guided Erector Spinae Plane Block in Patients Undergoing Open Epigastric Hernia Repair: A Prospective Randomized Controlled Study.
Hernia repair is associated with considerable postoperative pain. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in patients undergoing open midline epigastric hernia repair (T6-T9). ⋯ Ultrasound-guided bilateral erector spinae plane block provided lower postoperative visual analog scale pain scores and decreased consumption of both intraoperative fentanyl and postoperative rescue analgesia for patients undergoing open epigastric hernia repair.