Current opinion in anaesthesiology
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Recently, there has been considerable interest in regional anaesthetic techniques, particularly in peripheral nerve blockade, for orthopaedic limb surgery. Many traditional nerve-block techniques have been significantly modified to improve their role in both in-patient and out-patient surgery. The introduction of long-acting local anaesthetic with a better safety profile as well as better equipment for continuous nerve blockade has further increased the use of such techniques in the provision of postoperative analgesia. The recent developments described in this review are likely to result in wider use of these techniques in years to come.
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Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions including antihypertensive effects as well as the ability to potentiate the effects of local anesthetics. It can provide pain relief by an opioid-independent mechanism. It has been shown to result in the prolongation of the sensory blockade and a reduction in the amount or concentration of local anesthetic required to produce perioperative analgesia. ⋯ In another study, the effects of clonidine used for intra-articular administration in combination with morphine were investigated. These authors found a significantly higher rate of satisfaction in the group of patients receiving clonidine plus morphine. Although several recent studies have shown certain benefits from the use of clonidine for regional anesthesia, further investigations are necessary to clarify its role.
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Surgical trauma and anaesthetics may cause immune suppression, predisposing patients to postoperative infections. Furthermore, stress such as surgery and pain per se is associated with immune suppression which, in animal models, leads to an increased susceptibility to infection and tumour spread. Thus, by modulating the neurohumoral stress response, anaesthesia may indirectly affect the immune system of surgical patients. ⋯ There is a striking body of evidence that long-term exposure to certain sedatives is paralleled by infectious complications. On the other hand, anti-inflammatory effects of anaesthetics may be therapeutically beneficial in distinct situations such as those involving ischaemia/reperfusion injury or the systemic inflammatory response syndrome. Consequently, sedatives should be administered with careful regard to their respective potential immunomodulatory properties, the clinical situation, and the immunity status of the critically ill patient.
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The cancer patient presents special challenges to the anesthesiologist. Cancer may have multiple effects including those due to the primary tumor, metastases, the effects and toxicity of cancer therapy, associated paraneoplastic and physiologic responses to the tumor and the strong psychological responses elicited by cancer. ⋯ Patient education and reassurance regarding issues of safety, pain control and respect for patient preferences are important goals as well. This review provides the anesthesiologist with both general and specific information important to the systematic and complete preoperative evaluation of the patient with cancer.
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Anaesthetic care of neurosurgical patients increasingly involves management issues that apply not only to 'asleep patients', but also to 'awake and waking-up patients' during and after intracranial operations. On one hand, awake brain surgery poses unique anaesthetic challenges for the provision of awake brain mapping, which requires that a part of the procedure is performed under conscious patient sedation. Recent case reports suggest that local infiltration anaesthesia combined with sedative regimens using short-acting drugs and improved monitoring devices have assumed increasing importance. ⋯ Recent data do not advocate a delay in extubating patients when neurological impairment is the only reason for prolonged intubation. An appropriate choice of sedatives and analgesics during mechanical ventilation of neurosurgical patients allows for a narrower range of wake-up time, and weaning protocols incorporating respiratory and neurological measures may improve outcome. In conclusion, despite a lack of key evidence to request 'fast-tracking pathways' for neurosurgical patients, innovative approaches to accelerate recovery after brain surgery are needed.