Current opinion in anaesthesiology
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Epidural blocks (caudal, lumbar or thoracic) are of common use in paediatric patients for special procedures such as open fundoplication as well as for postoperative analgesia. However, because neonates and infants have lower metabolic capacities and specific anatomy as compared to adults, the dose of local anaesthetics and the way of their administration need careful attention. ⋯ Pharmacokinetic studies allowing safer dosing, especially with ropivacaine have recently been published. New techniques of thoracic epidural with puncture at the lumbar level are also proposed. However, all these new techniques need to pass the test of time.
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As a result of its accompanying co-morbidity, our lack of understanding regarding its mechanisms, and its resistance to conventional treatment, central pain is one of the most formidable challenges pain physicians are faced with. The objective of this review is to summarize recent advances in our understanding of the etiology, clinical presentation, and treatment of central pain, with special emphasis being placed on studies published within the past year. ⋯ Injury to the spinothalamocortical pathways is a necessary, but not sufficient factor in the pathogenesis of central pain. Perhaps because of the similarities in mechanisms, there is considerable overlap between effective treatments for central pain and those for peripheral neuropathic pain. Our poor understanding of the etiology of central pain and the relative lack of effective treatments emphasize the need for further research into this elusive disorder.
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The alpha(2)-adrenoceptor agonist clonidine is one of the most widely investigated substances in anaesthesia and pain therapy. Recently, numerous experimental and clinical studies have allowed a better understanding of its underlying mechanisms of action and interactions with other analgesic drugs. ⋯ During the past decade clonidine has been investigated as an adjuvant for general and regional anaesthesia and in the postoperative period. There is no doubt that clonidine improves analgesia after systemic, spinal or peripheral opioids, and prolongs the analgesic action of most local anaesthetics. The side-effects of usual doses of clonidine are predictable. Given the clinical experience of an increasing number of hospitals, clonidine should no longer be considered an experimental drug, but a useful addendum to the pharmacological armamentarium.
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Major complications after intracranial surgery occur in 13-27% of patients. These complications may have multiple causes, but a body of arguments suggests that the haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. The aim of this review is to explain the rationale of this hypothesis and analyse the recent studies relevant to neuroanaesthesia recovery. ⋯ Pain, hypothermia, hypercapnia, hypoxia, hypoosmolality, hypertension, and anaemia should be avoided during emergence. Early emergence is associated with minimal haemodynamic and metabolic changes. If there is any doubt as to whether the patient should be extubated in the operating room, a gradual emergence in the intensive care unit makes it possible to decide whether or not extubation can be performed safely.
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In recent years there has been a renewed interest in regional anesthesia, particularly peripheral nerve blockade, in order not only to improve the patient's well being, but also to meet the requirements of modern orthopedic surgery. These requirements include appropriate conditions to perform early and efficient rehabilitation. ⋯ Early rehabilitation is currently a key point for the success of orthopedic surgery. The rapid development of peripheral nerve blockade gives the anesthesiologist the means to face this new challenge.