Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2012
ReviewFunctional outcome after major orthopedic surgery: the role of regional anesthesia redefined.
Regional anesthesia can provide optimal pain management and stress reduction. This article aims to establish the impact of regional anesthesia in facilitating the recovery process, measured by significant clinical outcomes. ⋯ In order to establish the role of regional anesthesia in functional outcome after major orthopedic surgery, assessment of pain control is no longer sufficient. New clinically relevant outcomes must be introduced and used for procedure-specific studies.
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Since the publication of original work on the transversus abdominis plane (TAP) block, the translation of the research into clinical practice has resulted in some 146 articles being published in peer-reviewed journals. However, there continues to be controversies over the best approach to be used. The introduction of ultrasound should have aided the development of this block, but in fact it has caused more questions to be asked. There are a number of reviews of the block already published, but were they published too early and what is our current understanding of the TAP block and its mechanisms of action? ⋯ The TAP block, in all its guises, is an effective analgesic tool, but what is the best approach? Randomized controlled trials comparing the TAP/RAFI blocks to epidural based analgesia are required.
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Curr Opin Anaesthesiol · Oct 2012
ReviewWhere should the tip of the needle be located in ultrasound-guided peripheral nerve blocks?
Data now exist describing the appropriate positioning of the needle tip and pattern of local anaesthetic spread after injection. The recent literature has been analysed in search of studies on the optimal procedure for common approaches centred on block efficacy, performance time, and safety. ⋯ The ultrasound appearance of nerves and target injections are better understood. The specific distributions of local anaesthetic spread that predict success are significantly different from one anatomical site to another. It seems advisable to avoid intraneural injection.
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Curr Opin Anaesthesiol · Oct 2012
ReviewLocal anesthetic 'in-situ' toxicity during peripheral nerve blocks: update on mechanisms and prevention.
Peripheral nerve blocks induce undesired side-effects linked to the toxicity of local anesthetics on neuron and myocytes via different cell targets. The effects of local anesthetics on these targets are now well known and summarized in this review. ⋯ Phenotypic analyses revealed that local anesthetics could induce histological damage with lesions ranging from local to extreme in skeletal muscle. Metabolic alterations were also described involving sarcoplasmic reticulum and calcium dysregulation, alteration of mitochondrial physiology and of oxidative phosphorylation with associated overproduction of harmful reactive oxygen species, typically leading to apoptosis or necrosis. Biochemical and cell biology investigations now indicate that local anesthetics interact with different molecular targets in mammalian cells as respiratory chain complex I or the prosurvival kinase Akt. Functional dysfunction in both muscle and neuron remains to be investigated with caution in patients, as local anesthetic toxicity remains under-evaluated. Likewise, the use of adapted local anesthetics in patients with particular diseases and neuromuscular disorder could further reduce the risk of undesired effect.We need to improve our practice, and the optimization of our clinical protocol could prevent from these side-effects. Lastly, experimental studies highlight the preventive effects of antioxidant drugs or of recombinant human erythropoietin but the pharmacokinetic feature of such strategies remain to be evaluated.