Ann Acad Med Singap
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The development of new non-depolarizing neuromuscular blocking drugs starting with the introduction of the intermediate-acting agents atracurium and vecuronium has made it possible to avoid the use of succinylcholine for elective cases. Recently 4 new drugs have become available; the short-acting mivacurium, the intermediate-acting rocuronium and the 2 long-acting drugs doxacurium and pipecuronium. The pharmacokinetic and pharmacodynamic profile of these drugs are reviewed in this paper.
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In recent years tremendous progress has been made in our understanding of peripheral, spinal cord and brain mechanisms involved in acute pain and in the neurophysiologic description of nociceptive pathways, receptors and mediators. Great strides have been made in our knowledge of pharmacokinetics and pharmacodynamics of drugs used to treat pain. However, in spite of unprecedented interest in pain and its management, most patients undergoing surgery still receive treatments that have changed little in the past decades. ⋯ Various combinations of the above are also possible. However, it is increasingly recognised that the solution to the problem of inadequate pain relief on surgical wards lies not so much in the development of new drugs and new techniques but in the development of a formal organisation for better use of existing drugs and techniques. A simple, low-cost organisation model for acute pain services (APS) is described.
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Extracorporeal life support (ECLS), which is prolonged cardiopulmonary bypass with an artificial membrane lung, is one of the most efficient life support means for patients with severe cardiopulmonary failure. Its practice will become much simpler, safer and popular in the near future. In this article, the history of ECLS and the acronyms related to it, together with its present status in the world are introduced. ⋯ Heparin-bonded hollow-fibre lungs made of non-microporous membrane are recommended for prolonged cardiopulmonary bypass to prevent gas embolism and fluid leakage from the artificial lungs. Several special clinical cases where patients were saved from moribund cardiopulmonary failure, such as severe barotrauma after excessive ventilator therapy and prolonged cardiac standstill after myocardial infarction, are described to explain the life-support effects and indications of ECLS. Research on ECLS, now taking place, such as the use of an intravenacaval oxygenator, manually operated cardiopulmonary bypass system for emergency resuscitation and transportation of the patient, as well as respiratory care of a premature newborn in artificial amnion fluid, is also introduced.
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Continuous spinal anaesthesia is an established technique in which renewed interest has been generated by the availability of small bore catheters suitable for use in the subarachnoid space. Problems include technical difficulty, post dural puncture headache and maldistribution of local anaesthetic, the latter being implicated in the development of caudal equina lesions. Maldistribution of local anaesthetic may possibly be reduced by attempting to place the tip of the catheter at the apex of the lumbo-sacral curve and the use of local anaesthetic solution that is only marginally hyperbaric. This article is in the form of a short review together with an account of the authors' own studies of continuous spinal anaesthesia, conducted to assess the technique for peripheral vascular surgery.
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Patients undergoing surgery move through a continuum of medical care to which a primary care physician, an internist, an anaesthesiologist, and a surgeon contribute to ensure the best outcome possible. No aspect of medicine requires greater cooperation than the performance of surgery and the perioperative care of a patient. For the anaesthesiologist, this responsibility should start in a preoperative clinic. ⋯ At a time when medical information is encyclopaedic, it is difficult for even the most conscientious anaesthesiologist or surgeon to keep abreast of medical issues relevant to perioperative patient management. Thus, a proposed preoperative assessment clinic facilitates those most sought-after goals, increased quality and reduced costs. As part of this process, ordering only laboratory tests warranted by a patient's symptoms and medical history is important to avoid risks of unnecessary testing and of follow-up of false-positive results.