Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Dec 2006
ReviewWhich muscle relaxants should be used in day surgery and when.
After myorelaxants, myalgia and residual curarization may complicate recovery. Local anaesthesia and minimally invasive airway management make myorelaxants disputable in many outpatient procedures; nevertheless, neuromuscular blockade may be necessary to facilitate intubation or maintain muscle relaxation. Agent selection criteria are discussed. ⋯ Ear-nose-throat, open eye surgery and laparoscopy may demand myoresolution. Regional and minimally invasive anaesthesia are alternative solutions. Central and peripheral nerve blocks are associated with increased induction time, reduced pain scores, and decreased need for analgesics. Central neuraxial block, however, is associated with prolonged outpatient unit stay. Bad intubating conditions may cause pharyngo-laryngeal complications: the decision to avoid myorelaxants for tracheal intubation appears illogical. Incidence of postoperative residual curarization remains very high. Sugammadex offers new perspectives.
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Curr Opin Anaesthesiol · Dec 2006
ReviewPharmacology, pharmacogenetics, and clinical efficacy of 5-hydroxytryptamine type 3 receptor antagonists for postoperative nausea and vomiting.
The use of selective 5-hydroxytryptamine type 3 receptor antagonists has improved the management of postoperative nausea and vomiting, but has not completely eliminated it. In this article, we discuss the pharmacology of 5-hydroxytryptamine type 3 receptor antagonists and the impact of pharmacogenetics on postoperative nausea and vomiting. ⋯ Pharmacogenetics testing in patients may help differentiate responders to 5-hydroxytryptamine type 3 receptor antagonists from non-responders and allow the anesthesiologist to individualize antiemetic therapy. The cost-effectiveness of such screening in postoperative nausea and vomiting management has, however, not been evaluated. Given the multifactorial nature of postoperative nausea and vomiting, a multimodal approach to reduce or eliminate risk factors will be most successful in its management.
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Curr Opin Anaesthesiol · Dec 2006
ReviewNitrous oxide in ambulatory anaesthesia: does it have a place in day surgical anaesthesia or is it just a threat for personnel and the global environment?
Nitrous oxide is by far the oldest anaesthetic still in routine use and its continued use is often questioned. Nitrous oxide is toxic with prolonged exposure, can damage the environment, causes pressure effects through expansion of closed air-filled spaces and has long been suspected of being harmful following chronic exposure to trace concentrations. What could possibly justify the continuing use of nitrous oxide? ⋯ Not only is nitrous oxide almost certainly less hazardous than is sometimes perceived, it has numerous benefits which are not easily replicated by possible alternatives. In particular, its use improves the quality and safety of induction and maintenance of anaesthesia and facilitates faster recovery with minimal adverse effects. All of these benefits are achieved while at the same time reducing overall costs. With few significant drawbacks and numerous advantages, there appears still to be a valuable place for nitrous oxide in modern ambulatory anaesthesia.
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An increasing number of day-case surgical patients is challenging the presently used methods of anaesthesia: reliable surgical anaesthesia should be fast, with rapid recovery and minimal side effects. To compete with modern ambulatory general anaesthesia a knowledge of special spinal anaesthesia techniques is essential. This review brings together important issues concerning the spinal technique, anaesthetic agents and benefits as well as the disadvantages of spinal anaesthesia in outpatients. ⋯ To produce reliable spinal anaesthesia with a reasonable recovery time it is essential to understand the factors affecting the spread of spinal block and to choose the optimal drug and adequate dose for specific surgical procedures.
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More surgery on children is being carried out on a day-case basis and we review the anaesthetic management. Selection of appropriate patients and procedures is vital and careful preparation of children and families minimizes fear and anxiety and streamlines the organizational aspects of care. Simple, noninvasive general-anaesthetic techniques with modern agents are recommended. Good analgesia is important and is based upon local or regional blockade, nonsteroidal antiinflammatory drugs and paracetamol, with opioids being reserved for rescue analgesia. Omission of opioids helps to minimize postoperative emesis. Discharge home is facilitated by clear instructions about activities, dressings, wound care and continuing pain control. ⋯ Children benefit particularly from day care and recent advances in anaesthesia and pain management have allowed a huge expansion of this modality of care with a consequent reduction in the need for children to be in hospital.