British journal of anaesthesia
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Review Meta Analysis
Thoracic paravertebral blocks in abdominal surgery - a systematic review of randomized controlled trials.
Thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multimodal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery. We performed a systematic review of randomized controlled trials, to clarify the impact of TPVB on perioperative analgesic outcomes in adult abdominal surgery. ⋯ The reported primary block failure rate was 2.8% and the incidence of complications was 1.2% (6/504); there were no instances of pneumothorax. TPVB therefore appears to be a promising analgesic technique for abdominal surgery in terms of efficacy and safety. But further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anaesthesia techniques.
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Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. ⋯ Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.
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Review
Vascular surgery-related organ injury and protective strategies: update and future prospects.
Whilst there has been a reduction in the prevalence of peripheral vascular disease worldwide, a significant proportion of the world's growing population is still affected by disease of the aorta, carotid, iliac and lower limb arteries. These if left untreated can result in severe morbidity and mortality. However vascular surgery, the main definitive treatment for such conditions, is associated with subsequent injury to vital organs including the kidneys, heart, brain, intestines and lungs, with a consequent increase in both morbidity and mortality. ⋯ Various methods to alleviate such injuries have been investigated including pre- and postconditioning strategies, pharmacological therapies including volatile anaesthetic and alpha2 adrenoceptor agonist drugs and more recently remote conditioning strategies. Although these interventions have demonstrated some reduction in the biomarkers for organ injury, attempts to translate these benefits into clinical practice have not been successful in terms of morbidity, mortality or length of hospital stay. For this reason, further research is needed in this area to facilitate the translation of the potential interventional benefits from bench to bedside.
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Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. ⋯ The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.