Minerva anestesiologica
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Minerva anestesiologica · May 2003
Review[Prevention of hypotension in spinal anaesthesia carried out for caesarean section].
After describing the most commonly applied obstetric indications for caesarean section and the respective percentages reported in countries that are comparable with Italy in terms of health care standards, the clinical reasons and requirements on the basis of which it is considered that spinal anaesthesia is first choice compared to general anaesthesia in obstetrical surgery are outlined. This evidence is confirmed by the spinal anaesthesia/general anaesthesia ratio encountered in the major national and international Obstetric Hospitals. Maternal hypotension remains the most frequent and clinically important complication consequent on spinal anaesthesia in pregnant women at term. ⋯ It is pointed out that certain procedures have become part of standard practice but their effectiveness has not yet been confirmed while others are not only ineffective but also expose mother and foetus to potential complications. For others again the jury is still out on their real effectiveness. Finally, the techniques that are currently considered to be effective and shared by the majority of authors are described and these must therefore be included in the procedural protocols regarding spinal anaesthesia for caesarean section.
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Minerva anestesiologica · May 2003
Review[Emergencies in cardiac surgery: prophylaxis or correction?].
Management of coagulation during cardiac surgery is always challenging for the anesthesiologist, even in elective operations. The strict linkage between coagulation and inflammation is amplified during cardiopulmonary bypass due to the contact of the blood with the foreign surfaces. In emergencies, coagulative derangement could be worse but the cardiocirculatory instability and parenchimal failure often overcome the attention to this problem.
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Minerva anestesiologica · May 2003
Review Comparative StudyPost-operative epidural versus intravenous patient-controlled analgesia.
Patient-controlled analgesia techniques have opened a new dimension to individualize patient's need for analgesia, in the treatment of acute post-operative pain. These techniques can be used intravenously, in the epidural space, and into peripheral nerve sheets. There is a common consensus that intravenous patient-controlled analgesia should not have a continuous infusion while epidural patient-controlled analgesia (PCEA) should be programmed with a continuous infusion. ⋯ The continuous epidural infusion of opioids has the advantages of fewer fluctuations in cerebrospinal fluid concentrations of drug, but it is necessary to administer a loading bolus, to overcome the fact that it takes several hours to provide adequate analgesia. The advantages of epidural versus intravenous patient-controlled analgesia are represented by better analgesia and a reduced opioids requirement, while the advantages when compared to epidural continuous infusion are: increased efficiency, self-adjustment by the patient, higher patient satisfaction, less sedation, and lower opioids dosage. The clinical advantages of PCEA may outweigh the greater cost and invasiveness of this technique.
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Minerva anestesiologica · May 2003
Review[Anesthesia for neurosurgery in children: techniques and monitoring].
Pediatric neuroanesthesia can be seen as a specific branch of anesthesia half way in between pediatric anesthesia and neuroanesthesia. As a matter of fact, we must keep well in mind the peculiarities of the pediatric patient and the different pharmadynamic and pharmacochinetic properties of the anesthetic drugs, particularly in neonates and infants. Other relevant problems are: 1) high complexity of surgical procedures implying a difficult anesthesiological management; 2) complex blood loss management either if we want to apply a blood sparing technique strategy or if we consider the problems related to diagnosis and treatment of coagulative disorders caused by intraoperative massive blood loss; 3) management of patients with latex allergy for the high incidence, in pediatric neuroanesthesia, of patients belonging to high risk groups; 4) need of repeated radiological examinations implying several anesthesiological procedures. In this article aspects related to the anesthesiological techniques and to the hemodynamic and neurophysiological monitoring of pediatric neurosurgical patients were also discussed.
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Minerva anestesiologica · May 2003
ReviewGuidelines on anticoagulants and the use of locoregional anesthesia.
Growing numbers of patients are treated with hemostasis altering drugs, as thromboembolic diseases are a major cause of mortality in our western society. The insertion of epidural or subarachnoidal needles and/or catheters in such patients carries the inherent risk of the development of a compressing vertebral canal hematoma. This is especially true in patients treated with thrombolytic agents or oral anticoagulants. ⋯ The available data do not allow making firm recommendations on the safe use of major neuraxial blocks. In contrast, the isolated use of acetyl-salicylic acid or non-steroidal anti-inflammatory drugs is no longer considered contraindicated, but their combination with of heparin remains controversial. Intraoperative heparinization, perioperative thromboprophylactic use of unfractionated heparin or low molecular weight heparins are possible if: 1) a minimum time interval between the regional anesthetic block and the administration of the previous or next dose of anticoagulant is respected and; 2) the specified dose limitations of the heparin compound used are not exceeded; and 3) indwelling catheters are removed only after the disappearance of any remaining anticoagulant effect.