Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Jun 2012
ReviewEpidural analgesia and maternal fever: a clinical and research update.
Maternal fever following epidural analgesia complicates up to one-third of nulliparous labors. Although generally benign, maternal fever is associated with both excess healthcare costs and an increased risk of adverse maternal and neonatal outcomes; therefore, this topic is of interest to anesthesiologists, obstetricians and pediatricians alike. The purpose of this review is to examine the latest research on the topic of epidural-related maternal fever, with special focus on the clinical relevance of new information. ⋯ Significant research advances were made in the last 18 months around the topic of epidural-related fever, but major gaps in knowledge persist especially with understanding the precise mechanism. The most pressing area of research is the development of well tolerated and effective prophylactic interventions to prevent maternal and fetal exposure to hyperthermia and inflammation.
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Clinical studies and new guidelines are frequently being published in the area of preoperative fasting. A growing population of patients with obstructive sleep apnea is being referred for outpatient procedures including adenotonsillectomy. ⋯ A more liberal preoperative intake is encouraged with fasting for 2 h for clear liquids, 4 h for breast milk, 6 h for formula and light meals, and 8 h for heavy meals is widely accepted. Interpersonal variation in residual gastric volume exists. Children with obstructive sleep apnea under 3 years of age and those with severe obstructive sleep apnea and comorbidities are not candidates for ambulatory surgery. Polysomnography has specific preoperative indications. Dexmedetomidine can decrease emergence agitation and has an opioid-sparing effect. Intravenous acetaminophen is presented as an opioid-sparing analgesic. Dexamethasone is effective in preventing postoperative nausea without increased risk of bleeding. Surgical techniques may affect postoperative pain.
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Curr Opin Anaesthesiol · Jun 2012
ReviewThe role of recombinant activated factor VII in obstetric hemorrhage.
To review the literature regarding the use of recombinant activated factor FVII (rFVIIa) in the treatment of postpartum hemorrhage (PPH). ⋯ Although some preliminary guidelines have been published, the case reports and case series illustrate that the practice of using rFVIIa in PPH is far from uniform. rFVIIa should usually not be used to compensate for an inadequate transfusion therapy. Therefore, early and effective administration of red blood cells, fresh frozen plasma, fibrinogen concentrate (or cryoprecipitate), and platelets as well as the control of uterine atony are essential before considering administration of rFVIIa in the treatment of PPH.
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This review assesses the maternal and fetal effects of vasopressor administration during spinal anaesthesia for caesarean delivery, with emphasis on recent findings. ⋯ Phenylephrine is the current vasopressor of choice for the prevention of maternal hypotension and nausea. Phenylephrine regimens need to be developed that can reliably and safely be used with noninvasive blood pressure cycle times less frequent than every minute. Further vasopressor should be used with caution when vagolytic therapy is, quite rightly, used to treat bradycardia associated with hypotension.
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Curr Opin Anaesthesiol · Jun 2012
ReviewPreoperative evaluation, premedication, and induction of anesthesia in infants and children.
Preparation for and induction of anesthesia in children has evolved significantly over the last decade, with particular reference to the reduction of perioperative anxiety reduction by nonpharmacologic and pharmacologic means. Several new large population studies and meta-analyses further scrutinize the current techniques. ⋯ Larger studies still need to be conducted before wide-scale application of many nonpharmalogical interventions such as parental acupuncture. Similarly, more investigation should be done on outcomes such as onset, emergence, and discharge times, as well as the postoperative response with reference to emergence delirium and postoperative nausea and vomiting prevention to outline the differences among sedative premedications such as midazolam, clonidine, and dexmedetomidine.