Current opinion in anaesthesiology
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There has been a growing interest in elucidating the immune consequences of opioid administration for the management of pain. Several studies in vitro and in vivo have demonstrated an immunomodulating effect of opioids. The neuro-endocrine interactions observed after opioid application contribute to this effect as well as direct alterations of immune effector cells. Opioid-induced immunomodulation is mediated by opioid receptors found on immunocytes and in the central nervous system. This review will elucidate the molecular mechanisms of central and peripheral immunomodulation by opioids with special emphasis on the clinical significance of these findings. ⋯ Although immunomodulating effects of opioids are well established, a final statement regarding the clinical relevance cannot be made, since the existing clinical and experimental data are preliminary and inconclusive. Therefore, further clinical studies are mandatory to elucidate the influence of opioid treatment on immune regulation in different clinical settings. Further investigations may help to provide sufficient analgesia by application of opioids, as well as assessing the advantages and disadvantages on immune function.
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The complexity of pain processing in clinical pain conditions and in animal models has revealed many time-related changes and an abundance of molecular drug targets. There continues to be insecurity, however, about new target validation in clinical pain and thus most analgesia development is of high risk for evolving new pain therapies. The present review highlights a number of molecular targets being pursued for pain control. ⋯ Many molecular targets have been highlighted with some being the focus of current analgesia research. Some of these (e.g. vanilloid receptor 1, cannabinoid receptor 1, sodium channel NaV 1.8) have been evaluated in animal studies and in preliminary clinical studies, but others are highly novel and riskier analgesia pain targets (e.g. metabotropic glutamate receptors, sensory neurone specific receptors, kinase inhibitors).
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Curr Opin Anaesthesiol · Oct 2003
Peripheral nerve blocks for anaesthesia and postoperative analgesia.
Perioperative analgesia is a major concern for the patient and for the anesthesiologist, whose task is to avoid pain and all related complications on immediate outcome and healing. Regional anesthesia, alone or combined with general anesthesia, is becoming a preferred technique in a variety of surgical procedures. There is increasing interest in peripheral nerve blocks, single or continuous, mainly for perioperative treatment of unilateral surgery. Specificity of analgesic area combined with decreased complications, including spinal or epidural hematoma, urinary retention, or hemodynamic alterations, are advantages of the peripheral nerve block over more central neural blocks. ⋯ Possibilities afforded by the use of peripheral nerve blocks mainly consist of prolonged analgesia, selective area of action, and fewer collateral effects when compared with general anesthesia or more central neural blockade. Introduction of new devices and new techniques are increasing, as evidenced by the large number of studies which have appeared in the literature during the past year.
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The use of regional techniques in paediatric anaesthesia has increased dramatically. Our aim is to produce a comprehensive review of the recent literature on neuraxial blockade in infants and children, focusing on three topics: choice of local anaesthetic and adjunct drugs, technical aspects and complications. ⋯ It is likely that the use of epidural ketamine or clonidine as adjuncts to local anaesthetics will grow. Alternatives, such as midazolam, may offer advantages in particular circumstances, although rigorous evaluation of the safety of these solutions when injected along the neuraxis and the development of formulations without preservatives are needed. The use of stimulating caudal catheters or ultrasound-guided techniques appears to offer promising options for the future to more accurately position catheters.
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The present overview will try to summarize the most important recent studies performed on spinal analgesia for labor pain treatment and spinal anesthesia for Cesarean section. ⋯ The new local anesthetics have established their position in obstetric regional anesthesia, but it remains difficult to demonstrate a superior outcome as compared with bupivacaine. The same is true for combined spinal-epidural and ambulation. Phenylephrine seems to have become the vasopressor of choice in the treatment of hypotension following spinal anesthesia. A more appropriate treatment of hypotension combined with a low-dose technique may enhance the safety of spinal anesthesia in preeclamptic patients or cases of severe cardiac disease.