Current opinion in anaesthesiology
-
Curr Opin Anaesthesiol · Oct 2003
Complications and local anaesthetic toxicity in regional anaesthesia.
Local anaesthetic agents are administered every day in clinical practice. These agents are relatively safe when administered in proper dosages at appropiate anatomical sites. However, when excessive dosages are administered or the incorrect site of administration is used there is a potential for toxic reactions. Ropivacaine, a pure S-enantiomer, and levobupivacaine, a single isomer of bupivacaine, have been introduced as new long-acting local anaesthetic agents with a potentially reduced toxicity compared with bupivacaine. The present review deals with recent knowledge about systemically induced local anaesthetic toxicity and localized toxicity. ⋯ Current evidence suggests that ropivacaine is slightly less toxic than levobupivacaine; however, the difference in potency between the two agents is greater. The new local anaesthetic agents can be regarded as 'safer', but must not be regarded as safe.
-
The practice of office-based anesthesia is quickly emerging as an important field for the anesthesia provider. The number of procedures being done in offices around the country has steadily increased, as has the invasiveness of these procedures. This creates new anesthetic considerations. To date most training programs have not addressed this area of practice. As practitioners enter the field, however, they should have information as to how to provide quality care in a location where very often they are completely alone. Many of the safety mechanisms we as anesthesia providers take for granted in a hospital setting are often not present in a surgical office, and it becomes our responsibility to help in establishing standards. ⋯ As office-based anesthesia continues to mature as a specialty, we the anesthesia providers must be proactive in establishing guidelines and recommendations to make the practice safe. We should be informed of the rules and regulations that exist in our states, and we should provide a voice for the patients who put their faith in us.
-
Correcting the fluid status of the surgical patient is an integral part of good anaesthetic practice. There have been few areas in anaesthesia and perioperative medicine as controversial as fluid resuscitation. Uncertainties still exist as to what the best solution to give is, whether it be a colloid or a crystalloid, and how and when to give it. As well as increasing awareness of the different properties of various colloids, there has been interest in the nature of the carrier solutions, essentially a choice between saline or Ringer's lactate (compound sodium lactate or Hartmann's solution). In this article we review recent studies involving crystalloids, the 'new colloids', and on the amount and timing of fluid therapy. ⋯ Compared with Ringer's lactate, saline, and saline-based colloids are associated with a hyperchloremic metabolic acidosis, and a hypocoagulable state although they may not be associated with adverse patient outcomes. Increasing awareness of the 'Stewart hypothesis' has led to new ways of managing hyperchloremic metabolic acidosis. The 'crystalloid-colloid debate' continues, and has led to an awareness that these different fluids, along with their carrier solutions are drugs with different effects. Several studies, in which patients have received more fluid in the protocol group, have found better clinical outcomes in the 'optimized' patients.
-
Curr Opin Anaesthesiol · Aug 2003
Brachial plexus blocks: infusions and other mechanisms to provide prolonged analgesia.
Regional anesthesia has numerous benefits for upper extremity surgery such as improved analgesia, opioid sparing and reduced side effects. However, many of these advantages are lost after block regression. Recently, several strategies such as continuous ambulatory local anesthetic infusions and adjuvants that may potentiate analgesia after a brachial plexus block have been described and investigated. This review will highlight and place in context this recent work. ⋯ The advances and techniques recently described demonstrate that prolonging analgesia after brachial plexus blocks is possible. This may be accomplished via several different approaches and mechanisms resulting in improved patient analgesia and side effects.
-
Curr Opin Anaesthesiol · Aug 2003
Challenges facing the anesthesiologist in the emergency department.
This review focuses on developments in airway management and concious sedation/analgesic techniques employed by anesthesiologists in the emergency department. ⋯ The consultant anesthesiologist responding to a critical airway may face a variety of challenges, including traumatized or soiled airways, patients with cervical spine fractures, and patients who have undergone sedation techniques that may have progressed to deep and general anesthesia. Anesthesiologists may also face the challenge of responding to these emergent situations without all the equipment or adequately trained support staff necessary to handle those emergencies safely.