Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Aug 2013
ReviewPeripheral nerve blocks for outpatient surgery: evidence-based indications.
There has been an increasing use of peripheral nerve blocks (PNBs) in ambulatory surgery. Several recent reports have contributed to our understanding of the optimal PNB technique for specific surgical procedures in this setting. In this review, we have summarized the available literature on indications of PNBs for outpatient surgery of the upper extremity. ⋯ ISBPB is currently the most beneficial PNB for outpatient shoulder surgery. Supraclavicular block functionally can be considered an alternative to the traditional ISBPB; however, additional studies are required before routine use can be recommended. Although the review identified several reports with benefits of one PNB technique over the others, the existing literature suggests that many of these techniques may be interchangeable with regards to procedures of the distal upper extremity. Future studies are indicated to help standardize the techniques, selection, and postoperative management of PNBs for specific surgical indications.
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Curr Opin Anaesthesiol · Aug 2013
ReviewManagement of the anticipated and unanticipated difficult airway in anesthesia outside the operating room.
The number of diagnostic and interventional procedures outside the operating room has dramatically increased over the last years. However, providing well tolerated anesthesia with the same standard of care in these locations is often challenging to the anesthesiologist. The remote locations include different organizational aspects and hazards. Airway management in general is still confronted with scenarios of difficult intubation and ventilation and often leads to significant morbidity and mortality. Continuous awareness of the potential complications is urged when providing anesthesia for remote procedures. ⋯ Airway management outside the operating room is challenging and needs the implementation of algorithms including the new airway devices. The recent update of the practice guidelines about difficult airway management of the American Society of Anesthesiologists remains the standard reference guide.
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To evaluate the most recent publications in the long-lived debate over the use of etomidate in critically ill septic and trauma patients. ⋯ A single dose of etomidate supplies good intubation conditions with hemodynamic stability, but increases the risk for adrenal insufficiency. The relative importance of these characteristics for the patients' outcome remains controversial, as there is a lack of direct evidence. According to the principle 'nihil nocere', reasoning argues against its use, especially in septic patients or in those at major risk to develop septic complications (e.g. trauma patients).
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Poor pain management has continued to be a problem after pediatric surgery. This review examines the current situation and recent advances in the area. ⋯ The concept of multimodal analgesia including the use of regional analgesic techniques is governing the current developments and discussions in the area of pediatric postoperative analgesia.
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Curr Opin Anaesthesiol · Aug 2013
ReviewContinuous renal replacement therapy with regional citrate anticoagulation: do we really know the details?
A significant proportion of critically ill patients with acute kidney injury require continuous renal replacement therapy (CRRT). This article summarizes current evidence on the diagnosis and treatment of acute kidney injury. Regional citrate anticoagulation (RCA) is an emerging but complex technique. A variety of solutions and systems are currently used for RCA. Descriptions of the dosage and methods differ significantly and may cause confusion in everyday practice. This article reviews important scientific findings and highlights pharmacological and pathophysiological aspects of RCA, with a special emphasis on practical clinical issues regarding dosage and available citrate solutions. ⋯ RCA-CRRT is a technique that can be safely used in the majority of intensive care patients with severe multiple-organ failure. The range of citrate solutions available, the different methods in use--continuous venovenous haemofiltration, continuous venovenous haemodialysis and continuous venovenous haemodiafiltration--and the lack of a generally accepted complete CRRT 'set' have impeded implementation of the technique in clinical practice. Unresolved questions regarding dosage and assessment preclude evidence-based comparison in prospective, multicentre studies. For the moment, each institution has to develop a local working protocol. In clinical practice, detailed staff training and monitoring of possible metabolic disturbances for this complex intervention is essential.