Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2007
ReviewAn update on the role of opioids in the management of chronic pain of nonmalignant origin.
To summarize and reflect over primarily recent epidemiological and randomized controlled trials in opioid-treated chronic nonmalignant pain patients, focusing on effects, side effects, risks and long-term consequences of the treatment. ⋯ Much more research is needed concerning long-time effects and consequences of opioid therapy in chronic nonmalignant pain patients; however, some clear warning signals have been sent out within recent years.
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Curr Opin Anaesthesiol · Oct 2007
ReviewHypertonic saline solutions for treatment of intracranial hypertension.
This review aims to provide an update on recent knowledge gained on hypertonic saline solutions for the treatment of intracranial hypertension. Explanatory approaches to the mechanisms underlying the edema-reducing effects of the solutions are outlined, practical aspects of use are presented, and trials that assessed their clinical utility are highlighted. ⋯ Hypertonic saline solutions have evolved as an alternative to mannitol or may be used in otherwise refractory intracranial hypertension to treat raised intracranial pressure. With high osmolar loads, the efficacy of the solution is enhanced, but no simple relationship between the saline concentration and the clinical effects of a solution is established. Caution is advised with high osmolar loads because they carry increased risks for potentially deleterious consequences of hypernatremia or may induce osmotic blood-brain barrier opening with possibly harmful extravasation of the hypertonic solution into the brain tissue.
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Nocebo hyperalgesia is a phenomenon that is opposite to placebo analgesia and whereby expectation of pain increase plays a crucial role. In recent times, both the neuroanatomical and the neurochemical bases of the nocebo effect and of nocebo-related effects have begun to be explored. Here, we highlight recent advances in our understanding of the neurobiology of the nocebo hyperalgesic effect. ⋯ Since pain appears to be amplified by anxiety through the activation of cholecystokininergic systems, new therapeutic strategies, such as new cholecystokinin antagonists, can be envisaged whenever pain has an important anxiety component.
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Paravertebral blocks are becoming increasingly popular, especially as an anesthetic adjunct for breast procedures. New reports suggest additional reasons for adding this block to the anesthetic armamentarium. ⋯ Paravertebral blocks are a well established option to provide anesthesia and postoperative analgesia during breast surgery. Recent studies suggest additional benefits to this procedure. Not only is acute pain better controlled, but the development of chronic mastectomy pain syndrome and recurrence of cancer may be reduced by preoperative placement of paravertebral block. These studies provide additional reasons why this block should be considered as part of the anesthetic for breast surgery.
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This review summarizes the current anesthetic management of patients undergoing craniotomies in the awake state. ⋯ A safe and acceptable analgesic/amnestic state for these procedures can be provided by the use of dexmedetomidine, with or without the addition of remifentanil.