Current opinion in anaesthesiology
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Sedation is a well recognized technique to improve patients' acceptance and comfort during regional anesthesia. The use of this technique is growing exponentially and is nowadays applied not only in the operating room but also in many other different locations within and outside the hospital. ⋯ The explosion of sedation well beyond the world of regional anesthesia has raised new challenges. Some sedative procedures will be performed more and more often by nonanesthesiologists in the future. This trend is inevitable due to limited resources and stresses on the importance of building up education and teaching programs for nonanesthesiologists. The need for reliable devices for monitoring of sedation and new hypnotics, which have even better phamacokinetics than those available, are needed to match the new issues of sedation.
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Perioperative transfusion thresholds in the neurosurgical patient are undefined. Many neurosurgical procedures are associated with significant risk of bleeding. This review will summarize the current understanding of blood transfusion in the neurosurgical patient, as well as other blood component therapies and blood conservation strategies. ⋯ Perioperative transfusion management for intracranial neurosurgical procedures presents the clinician with multiple challenges. Clinical evidence is sparse with view to an optimal hemoglobin level, yet anemia is known to be a predictor of poor outcome in many neurosurgical patients. Transfusion thresholds from other patient populations may not apply to this group and further prospective investigations are desperately needed. Until then, clinicians should focus on an individualized assessment of anemia tolerance, consider blood conservation strategies and understand the potential risks and benefits of blood transfusion.
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Curr Opin Anaesthesiol · Oct 2009
ReviewMultimodal analgesia for controlling acute postoperative pain.
Multimodal analgesia is needed for acute postoperative pain management due to adverse effects of opioid analgesics, which can impede recovery; a problem that is of increasing concern with the rapid increase in the number of ambulatory surgeries. Yet, the literature on multimodal analgesia often shows variable degrees of success, even with studies utilizing the same adjuvant medication. ⋯ There is a continuing need to explore new drug combinations to achieve all of the purported goals of multimodal anesthesia.
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In this review we focus on recent findings in the anesthetic management of patients undergoing craniotomy while awake, and propose a structured approach to the clinical practice of 'anesthesia' for awake neurosurgery. ⋯ Although anesthesia for awake craniotomy is usually a well tolerated procedure it requires an extensive knowledge of the principles underlying neuroanesthesia and of specific technical strategies including local anesthesia for scalp blockade, advanced airway management, dedicated sedation protocols, and skillful management of hemodynamics.
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Worldwide, the number of overweight and obese patients has increased dramatically. As a result, anesthesiologists routinely encounter obese patients daily in their clinical practice. The use of regional anesthesia is becoming increasingly popular for these patients. When appropriate, a regional anesthetic offers advantages and should be considered in the anesthetic management plan of obese patients. The following is a review of regional anesthesia in obesity, with special consideration of the unique challenges presented to the anesthesiologist by the obese patient. ⋯ Successful peripheral and neuraxial blockade in obese patients requires an anesthesiologist experienced in regional techniques, and one with the knowledge of the physiologic and pharmacologic differences that are unique to the obese patient.