Current opinion in anaesthesiology
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We critically review brain function monitors based on the processed electroencephalogram with regards to signal quality, artefacts and other limitations in clinical performance. ⋯ Clinicians should be aware of the several limitations of the commercial devices intending to monitor the depth of anaesthesia, which may not reflect the real underlying level of unconsciousness.
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Curr Opin Anaesthesiol · Dec 2011
ReviewArterial waveform analysis in anesthesia and critical care.
In this review, we describe the basic principles of arterial waveform analysis (AWA) to assess cardiac output (CO) and cardiac preload. The validity of commercially based hemodynamic monitoring systems is discussed, together with their clinical applications and limitations. ⋯ AWA provides a less invasive and easy-to-use alternative for CO measurement. The validity of AWA devices has been verified in a variety of patients and circumstances, but their performance is compromised in the presence of hemodynamic instability, cardiac arrhythmias, or other factors disturbing the arterial pressure waveform. The definitive role of dynamic preload parameters like SVV and PPV is a matter of research. Large trials in which the value of early goal-directed therapy using this technology is studied in relation to outcome are urgently needed.
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Curr Opin Anaesthesiol · Dec 2011
ReviewRevival of old local anesthetics for spinal anesthesia in ambulatory surgery.
In recent years, several older (first intrathecal use in the 1950s, 1960s, and 1970s) local anesthetics have been investigated as spinal anesthetics in ambulatory surgery because these drugs are claimed to cause less transient neurologic symptoms (TNS) than lidocaine which was the main spinal anesthetic for surgery of short-duration for decades. The review covers the current literature. ⋯ The newest results corroborate (at least for chloroprocaine, articaine, and prilocaine) previous data that these drugs provide reliable and mostly well tolerated spinal blocks associated with an apparently smaller risk for postanesthesic TNS as compared with lidocaine. Further studies are warranted regarding broader indications, possible usefulness of adjuvants, and for the exploration of the side-effect profiles in detail. To what extent the observed revival of these older, rather well characterized local anesthetics leads to a wider use of spinal anesthesia in the ambulatory setting remains to be seen. This is also dependent on various organizational and local traditional factors.
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Curr Opin Anaesthesiol · Dec 2011
ReviewRegional anesthetic procedures in immunosuppressed patients: risk of infection.
Due to demographic developments anesthesiologists encounter an increasing number of older and multimorbid patients in their daily routine. Consequently the proportion of immunosuppressed patients (e.g. those with cancer, diabetes mellitus, and those receiving immunosuppressive treatment and/or chemotherapy - e.g. for inflammatory bowel diseases, autoimmune diseases, and after transplantation) will also rise. Regional anesthesia (peripheral nerve blocks and neuraxial blockade) may be beneficial in these patients and will have to be considered in order to provide adequate pain management and minimize risks for the patients. ⋯ So far, there are no guidelines available dealing with indications and limitations of regional anesthetic procedures in these patients. The complication rate is rare but potentially disastrous. However, the technique itself cannot be regarded as absolute contraindication for immunosuppressed patients if precautions are taken. An interdisciplinary approach regarding the indication of regional anesthesia techniques in immunosuppressed patients is recommended. Efforts must therefore be made to achieve an interdisciplinary consensus with relevant risk-benefit considerations.
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Alpha-2-agonists have long been known to have anaesthetic-sparing, sedative and analgesic properties which are desirable in day case anaesthesia. Their routine use was hampered by a high incidence of undesirable effects, however. In recent years, there have been many attempts to define a role for these unique agents in which their benefits would outweigh their apparent disadvantages. ⋯ Alpha-2-agonists still have no clearly defined routine role in day surgery. Their most promising application is in limiting recovery agitation in children, but even here, there remain concerns about their routine use.