Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2010
ReviewIndications and management of continuous infusion of local anesthetics at home.
The review examines recent research activity in the field of continuous peripheral nerve blocks in the ambulatory setting and places it in context with regard to previous research efforts. ⋯ Continuous peripheral nerve blockade at home offers good short-term control of postoperative pain in the outpatient setting. Long-term outcomes remain to be evaluated fully. More information is becoming available on local anesthetic volume and concentration relationships in both the upper and lower extremities--optimal strategies are not yet clear. Ultrasound may offer benefits in terms of speed and ease of continuous catheter placement while reducing the necessary number of needle passes required to reach the target structure site(s).
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Curr Opin Anaesthesiol · Oct 2010
ReviewGlucose management in the neurosurgical patient: are we yet any closer?
This review focuses on recent findings in perioperative management of blood glucose control using intensive insulin therapy in neurosurgical and neurocritical care and in other intensive care unit patients. We also aim to address practical issues and make recommendations that may contribute to the safe clinical application of intensive insulin therapy targeted to optimize blood glucose control in these patients. ⋯ In neurosurgical and neurocritical care as well as other intensive care unit patients, both hypoglycemia and hyperglycemia have significant adverse effects. The optimal glucose level remains under debate but significant steps have evolved with the call for judicious control and elimination of the historical approach to glycemic management, which underestimated drawbacks associated with dysglycemia. The increased incidence of hypoglycemia and mortality as well as the impact of hyperglycemia on worsening neurologic function in patients with acute brain damage heightens the need for more clinical studies on perioperative glucose management in these patients.
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Curr Opin Anaesthesiol · Oct 2010
ReviewCurrent concepts and future trends in ultrasound-guided regional anesthesia.
Ultrasound guidance for regional anesthesia has gained enormous popularity during the past several years. This review article highlights the importance of acquiring an understanding and knowledge of human anatomy for well tolerated and effective performance of regional anesthesia; includes description of some of the major principles of ultrasound-guided regional anesthesia techniques (adequate identification of neuronal and adjacent anatomical structures along with the procedure needle); use of adequate volumes of local anesthetic and the proper administration of local anesthetic; and discusses economical along with educational aspects of ultrasound-guided regional blocks. ⋯ With little reservation, it is anticipated that ultrasound-guided regional anesthesia will become the 'GOLD' standard for performance of regional anesthesia. Excellent science and educational concepts will continue to be required with the continued increase in popularity of this exciting specialty of anesthesia.
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Curr Opin Anaesthesiol · Oct 2010
ReviewOpioid use in chronic noncancer pain: guidelines revisited.
The treatment of chronic noncancer pain with opioids is controversial. This review aims to find answers to three questions patients and physicians might have: how much (pain relief can be expected), how long (will pain relief be sustained) and how bad (are side-effects)? To this end, we reviewed the second generation of clinical guidelines on this topic. These are based on a significantly higher number of randomized controlled trials than former ones and, therefore, allow evidence-based statements. ⋯ Many guideline panels concentrate their recommendations solely on safety of opioid analgesics and patients are usually not informed about the (low) degree of pain relief to be expected. This makes adherence of patients unlikely. Beyond that, multimodal treatment of chronic noncancer pain should become the center of attention.
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Curr Opin Anaesthesiol · Oct 2010
ReviewConditioned pain modulation (the diffuse noxious inhibitory control-like effect): its relevance for acute and chronic pain states.
There is a growing body of knowledge on pain modulation in various disease states. This article reviews the state of the art regarding the clinical relevance of pain inhibition as revealed by 'pain inhibits pain' test paradigms, trying to organize the clinically relevant data, and emphasizing the pathophysiology of pain. In line with recent experts' recommendations, the term conditioned pain modulation (CPM) will be used, replacing the previous terms 'diffuse noxious inhibitory control (DNIC)' or 'DNIC-like' effects. ⋯ Low CPM efficiency is associated with higher pain morbidity and vice versa. Further work is awaited on clarifying plasticity of CPM and its relevance to selection and efficacy of pain therapy.