Current opinion in anaesthesiology
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Postdural puncture headache remains the most frequent complication of neuraxial anesthesia. It can occur following uncomplicated spinal anesthesia as well as unintended dural puncture during epidural anesthesia. ⋯ An epidural blood patch should not be performed until 24 h after dural puncture to increase its success; however, it should not be delayed beyond that period in the symptomatic patient, as this delay increases the amount of time the patient suffers.
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This review will outline old and recent data about the prevalence, causes and potential consequences of intraoperative awareness in children and give details on its detection. ⋯ Intraoperative awareness is a reality in school-aged children. A larger multicentre study and large-scale follow-up is required in order to confirm the higher incidence of awareness and identify the risk factors and long-term psychological sequelae of this complication in the paediatric population.
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There are still many controversies about perioperative management of hypertensive patients. This review aims to provide relevant instruction based on evidence regarding the treatment of those patients. ⋯ Delaying surgery only for the purpose of blood pressure control may not be necessary, especially in the case of mild to moderate hypertension. Strict care, however, should be taken to ensure perioperative hemodynamic stability because labile hemodynamics, rather than preoperative hypertension per se, appears to be more closely associated with adverse cardiovascular complications. Delaying surgery in hypertensive patients may be justified if target organ damage exists that can be improved by such a delay or if (suspected) target organ damage should be evaluated further before the operation.
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Curr Opin Anaesthesiol · Jun 2006
ReviewSome current controversies in paediatric regional anaesthesia.
Controversial topics in paediatric regional anaesthesia are discussed. ⋯ The performance of regional blocks in anaesthetized patients is generally contra-indicated in adults but accepted in children. Levobupivacaine displays the same pharmacokinetic profile as racemic bupivacaine with possibly less cardiac toxicity. Ropivacaine undergoes slower absorption and, in some studies, concomitant increase in peak plasma concentration in infants. Conversely, continuous infusion of ropivacaine offers the safest therapeutic index. Many adjuvants have been used but only epinephrine, clonidine, and preservative-free ketamine offer clear advantages. Midazolam and neostigmine are effective but have potential drawbacks and raise safety questions. Needle and catheter positioning is critical. Electrocardiogram guidance and electrical stimulation occasionally help identify the migration of epidural catheters. Stimulating catheters might be useful for continuous peripheral blockade. Ultrasonography will probably become the reference technique for peripheral catheter placement. Patients at risk of compartment syndrome must be monitored (measurement of compartmental pressures); adequate pain management does not 'hide' this complication but, on the contrary, can facilitate early diagnosis since the increase in requirement for pain medication precedes other clinical symptoms by an average of 7.3 h.
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Curr Opin Anaesthesiol · Jun 2006
ReviewRecent developments in airway management of the paediatric patient.
During the last two years, several studies have enhanced our knowledge about the influence of pharmacological agents and routine airway management manoeuvres on the airway of paediatric patients. New supraglottic airway devices have been introduced into routine paediatric anaesthesia practice, and the design of paediatric endotracheal tubes has been modified. This review summarizes the most recent and relevant scientific developments in paediatric airway management. ⋯ Remifentanil has found a place in airway management in paediatric patients. Recent improvements in the design of paediatric supraglottic airway devices and endotracheal tubes are promising. Further research is needed to consolidate their role in improving the perioperative outcome in paediatric patients.