Current opinion in anaesthesiology
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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.
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Curr Opin Anaesthesiol · Oct 2003
Epidural anaesthesia and analgesia for surgery: still going strong?
The discussion on the value of epidural anaesthesia and analgesia for surgery is fuelled by current controversies regarding effects on postoperative morbidity and mortality, potential benefits for outcome and the fear of rare, but catastrophic neurological complications. This review of the most recent publications on the topic since April 2002 illustrates some of the aspects contributing to the ongoing discussion. ⋯ In an era of evidence-based medicine, further meta-analyses and well-planned large randomized trials have to address the controversial issues of epidural anaesthesia and analgesia and postoperative outcome. In the context of a more holistic 'rehabilitative' management of the perioperative period, this technique might well represent a key factor to improve outcome, reduce hospital stay and thereby healthcare costs. Recent innovations and developments in techniques and drugs as well as established guidelines should further minimize potential errors and harmful complications.
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Curr Opin Anaesthesiol · Oct 2003
Complications and local anaesthetic toxicity in regional anaesthesia.
Local anaesthetic agents are administered every day in clinical practice. These agents are relatively safe when administered in proper dosages at appropiate anatomical sites. However, when excessive dosages are administered or the incorrect site of administration is used there is a potential for toxic reactions. Ropivacaine, a pure S-enantiomer, and levobupivacaine, a single isomer of bupivacaine, have been introduced as new long-acting local anaesthetic agents with a potentially reduced toxicity compared with bupivacaine. The present review deals with recent knowledge about systemically induced local anaesthetic toxicity and localized toxicity. ⋯ Current evidence suggests that ropivacaine is slightly less toxic than levobupivacaine; however, the difference in potency between the two agents is greater. The new local anaesthetic agents can be regarded as 'safer', but must not be regarded as safe.