Masui. The Japanese journal of anesthesiology
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The effect of adding vasoconstrictors to local anesthetics for spinal anesthesia is controversial. The aim of this study was to investigate the effect of phenylephrine on neural blockade and hemodynamic changes in spinal anesthesia in elderly patients. ⋯ The addition of phenylephrine to hyperbaric tetracaine in spinal anesthesia did not affect the extent of sensory blocks and hemodynamic changes in elderly patients.
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Surgical stress response affects the neuroendocrine system and depresses the immune function. Anesthetic induction drugs (except propofol), volatile anesthetics and opioids also have an immunosupressive effect. ⋯ Although some experimental studies and some clinical retrospective data show advantage of regional anesthesia over general anesthesia and opioid for postoperative analgesia, evidence level is still low and insufficient to prove its efficacy on postoperative mortality. Much more research and controlled clinical trials are needed to elucidate the advantage of the regional anesthesia in cancer operation.
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Anesthetic agents, especially, volatile anesthetics are considered to exert organ toxicity such as nephrotoxicity and hepatotoxicity; however, recent aggressive researches explored the beneficial effects of volatile anesthetics as an organ protectant. Ischemic preconditioning is a phenomenon in which single or multiple brief periods of ischemia have been shown to protect the myocardium and brain against prolonged ischemic insult. General anesthesia showed the protection against both ischemic myocardial and brain reperfusion injuries. ⋯ Neurotoxicities of anesthetic agents are very crucial problems for the patient and they are considered to be due to the activation of IP3 receptor in ER after exposure to volatile anesthetics. Massive release of Ca2+ from ER induces Ca2+ overload leading to mitochondria permeability transition (MPT) and induces apoptosis in the brain or aggravates the neurodegenerative disease. Susceptible mechanisms and beneficial treatment for the toxicity of general anesthesia is considered as a critical subject to discuss and challenge to solve for our future.
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Recent clinical studies suggest that intraoperative liberal crystalloid infusion causes postoperative edema and various systemic and local complications. Weight gain may be a promising predictor for postoperative complications. "No intravenous infusion should be continued simply because it is a 'routine' component of clinical care." as GIFTASUSP (British consensus of guidelines on intravenous fluid therapy for adult surgical patients) has suggested. Optimal titration of fluid infusion should be considered on the individual basis. ⋯ Unnecessary transfusion should be avoided and any effort to reduce transfusion should be recommended. Too-much or too-low infusion and transfusion causes adverse outcome. Optimizing the volume may be the key for ideal postoperative outcome.
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Reducing postoperative morbidity and mortality is important not only for patients' outcome but for reduction of financial burden on society. Precise and accurate preoperative evaluation of surgical risk factors is crucial to plan appropriate postoperative allocation of medical resources. American Society of Anesthesiologists physical status is a traditional measure to describe preoperative risk of patients undergoing surgery. ⋯ Charlson Age-comorbidity Index, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) are frequently used scoring systems. Several lines of evidence indicate that negligence of medical caregivers cause substantial numbers of errors to patients and often leads to severe complications or deaths. Full compliances to surgical checklists and implementation of medical team will help reduce these errors and lead to better patients' postoperative outcomes.