Current opinion in anaesthesiology
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This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. ⋯ Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.
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This review outlines the analgesic role of perineural adjuvants for local anesthetic nerve block injections, and evaluates current knowledge regarding whether adjuvants modulate the neurocytologic properties of local anesthetics. ⋯ Dexmedetomidine added as a peripheral nerve blockade adjuvant improves block duration without neurotoxic properties. The combined adjuvants clonidine, buprenorphine, and dexamethasone do not appear to alter local anesthetic neurotoxicity. Midazolam significantly increases local anesthetic neurotoxicity in vitro, but when combined with clonidine-buprenorphine-dexamethasone (sans local anesthetic) produces no in-vitro or in-vivo neurotoxicity. Further larger-species animal testing and human trials will be required to reinforce the clinical applicability of these findings.
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Using a regional block in a multimodal approach to postoperative analgesia management involves addressing, which local anesthetic and how much should be used to ensure adequate pain relief to reduce related morbidity and mortality. This article will review literature surrounding the recently approved formulation of slow release liposomal bupivacaine, define its proven benefits, and identify ongoing studies to further examine the utility of this novel formulation by various routes. ⋯ Current published data do not provide superior clinical results for EXPAREL over conventional bupivacaine based upon the lack of adequately powered multicentered clinical trials with comparison groups. Further investigation is necessary to identify the analgesic efficacy and safety profile of liposomal bupivacaine versus standard local anesthetics and to define the optimal clinical indication for liposomal bupivacaine administration in regional anesthesia.
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The goal of this review was to update the reader on the developments and advancements that have transpired in the previous few years and to encourage an open dialogue amongst readers and researchers alike. ⋯ The impact of paravertebral analgesia on cancer pain and prevention of metastasis could be huge once enough data have accumulated. The steady influx of data on PVBs has led to the resurgence of this block in almost every area of acute pain management.
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Curr Opin Anaesthesiol · Oct 2015
ReviewPreparing for budget-based payment methodologies: global payment and episode-based payment.
Use of budget-based payment methodologies (capitation and episode-based bundled payment) has been demonstrated to drive value in healthcare delivery. With a focus on high-volume, high-cost surgical procedures, inclusion of anaesthesiology services in these methodologies is likely. This review provides a summary of budget-based payment methodologies and practical information necessary for anaesthesiologists to prepare for participation in these programmes. ⋯ With significant opportunity to contribute to care coordination and cost management, anaesthesiology can play an important role in budget-based payment programmes and should expect to participate as full gainsharing partners. Precise costing methodologies and accurate economic modelling, along with identification of quality management and cost control opportunities, will help identify participation opportunities and appropriate payment and gainsharing agreements. Anaesthesiology-specific examples with budget-based payment models are needed to help guide increased participation in these programmes.