Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2010
ReviewAre there still limitations for the use of target-controlled infusion in children?
Target controlled infusion (TCI) devices are gaining popularity among paediatric anaesthesia practitioners because propofol and short-acting opioids allow rapid onset and offset of action, reduce postoperative nausea and vomiting, reduce emergence delirium, lessen exposure to atmospheric pollutants and can be used in peripheral locations. Widespread use remains limited and this review examines reasons why children do not yet enjoy such benefits. ⋯ Hardware limitations, a lack of integrated pharmacokinetic/pharmacodynamic studies and target monitoring issues restrict use. Intravenous induction remains a hurdle, but increasing familiarity with the technique guarantees continued use for maintenance anaesthesia.
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Labor is among the most painful experiences that humans encounter. Neuraxial analgesia is the most effective means of treating this pain. In this review, we discussed the effect of neuraxial analgesia on the progress of labor when compared with parenteral opioids. We then compared initiation of analgesia with a combined spinal-epidural technique (CSE) to conventional epidural analgesia. Finally we discussed the impact of neuraxial analgesia, given early in labor, compared with later administration. ⋯ Neuraxial analgesia does not interfere with the progress or outcome of labor. There is no need to withhold neuraxial analgesia until the active stage of labor.
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Curr Opin Anaesthesiol · Jun 2010
ReviewCan inhalation agents be used in the presence of a child with myopathy?
Anaesthesia for a child with a muscle disease is always challenging because there is a risk of malignant hyperthermia, rhabdomyolysis or hypermetabolic reaction if a halogenated agent is used. Ongoing progress in genetics helps in clarifying the link between malignant hyperthermia (a calcium channelopathy) and muscle diseases. ⋯ Only a few muscle diseases are really associated with a risk of malignant hyperthermia. The risk of rhabdomyolysis is more difficult to clarify and a multicentric database would be useful to evaluate the risk/benefit ratio of all anaesthetic drugs in patients with muscle diseases.
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Patients often receive preoperative therapies that interfere with hemostasis, and can present for surgery with underlying hemostatic disorders because of pre-existing preoperative anticoagulation or antiplatelet therapy. Perioperative bleeding can occur following surgery due to multiple causes; however, the addition of pharmacologic agents creates an acquired defect that complicates the surgical injury and may result in increased blood loss. An understanding of the potential impact of anticoagulation therapies on hemostasis is critical in managing these patients. Further, newer agents are evolving in clinical practice that clinicians should be aware of. ⋯ There are multiple pharmacologic therapies that surgical patients may be exposed to preoperatively, although there are currently few available methods to antagonize their effects. Often therapeutic prohemostatic pharmacologic approaches are used to treat or prevent bleeding, in addition to transfusional therapies.
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Curr Opin Anaesthesiol · Jun 2010
ReviewIs there any relationship between long-term behavior disturbance and early exposure to anesthesia?
There is now more than a decade of mounting animal data that anesthetic drugs can cause apoptosis during a critical period of brain development and that this correlates with later behavioral disturbances. Initial articles examining the effects of early anesthesia on human infants have recently been published. Prospective studies are underway. ⋯ Although the evidence from animal studies is clear and continuing to mount that anesthetic drugs given at the right time and in sufficiently high and prolonged doses do cause increased neuronal apoptosis and later problems with learning, evidence in humans that this is of clinical concern is both weak and mixed. Additional studies are ongoing to try to better define the risk.