Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2006
ReviewNitrous oxide in ambulatory anaesthesia: does it have a place in day surgical anaesthesia or is it just a threat for personnel and the global environment?
Nitrous oxide is by far the oldest anaesthetic still in routine use and its continued use is often questioned. Nitrous oxide is toxic with prolonged exposure, can damage the environment, causes pressure effects through expansion of closed air-filled spaces and has long been suspected of being harmful following chronic exposure to trace concentrations. What could possibly justify the continuing use of nitrous oxide? ⋯ Not only is nitrous oxide almost certainly less hazardous than is sometimes perceived, it has numerous benefits which are not easily replicated by possible alternatives. In particular, its use improves the quality and safety of induction and maintenance of anaesthesia and facilitates faster recovery with minimal adverse effects. All of these benefits are achieved while at the same time reducing overall costs. With few significant drawbacks and numerous advantages, there appears still to be a valuable place for nitrous oxide in modern ambulatory anaesthesia.
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An increasing number of day-case surgical patients is challenging the presently used methods of anaesthesia: reliable surgical anaesthesia should be fast, with rapid recovery and minimal side effects. To compete with modern ambulatory general anaesthesia a knowledge of special spinal anaesthesia techniques is essential. This review brings together important issues concerning the spinal technique, anaesthetic agents and benefits as well as the disadvantages of spinal anaesthesia in outpatients. ⋯ To produce reliable spinal anaesthesia with a reasonable recovery time it is essential to understand the factors affecting the spread of spinal block and to choose the optimal drug and adequate dose for specific surgical procedures.
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More surgery on children is being carried out on a day-case basis and we review the anaesthetic management. Selection of appropriate patients and procedures is vital and careful preparation of children and families minimizes fear and anxiety and streamlines the organizational aspects of care. Simple, noninvasive general-anaesthetic techniques with modern agents are recommended. Good analgesia is important and is based upon local or regional blockade, nonsteroidal antiinflammatory drugs and paracetamol, with opioids being reserved for rescue analgesia. Omission of opioids helps to minimize postoperative emesis. Discharge home is facilitated by clear instructions about activities, dressings, wound care and continuing pain control. ⋯ Children benefit particularly from day care and recent advances in anaesthesia and pain management have allowed a huge expansion of this modality of care with a consequent reduction in the need for children to be in hospital.
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To summarize and examine the updated published results on the outcome measures that can be used to assess the quality of ambulatory surgery and anesthesia. ⋯ Ambulatory surgery, as currently practiced, provides quality care that is cost-effective. Minor adverse events such as pain and postoperative nausea and vomiting are still common, and improvement could be targeted in these areas.
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Echocardiography has been used perioperatively as an important diagnostic tool since the 1980s. Introduction of this new technique has been beneficial to our practice, but has also introduced questions and issues related to methods of teaching, requirements for demonstration of competence and testing and certification processes as evidence of satisfactory completion of necessary learning parameters. This article will review the issues presented to date, how they have been addressed, and what options could be arriving in the future. ⋯ Perioperative echocardiography has rapidly become an integral part of anesthetic practice. The training and certification process has been formalized. There are still issues related to difficulty of training individuals outside core residency programs.