European journal of anaesthesiology. Supplement
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Eur J Anaesthesiol Suppl · Jan 2001
ReviewUse of reversal agents in day care procedures (with special reference to postoperative nausea and vomiting).
There is some confusion about the contribution of reversal of residual paralysis to the occurrence of postoperative nausea and vomiting. The aim of this review is to discuss whether antagonism of residual paralysis is a cause of postoperative nausea and vomiting, and to assess the risk of residual paralysis if the reversal is omitted. Data from a meta-analysis published before 1998 were considered, along with trials published after that date to assess the influence of reversal of residual paralysis on postoperative nausea and vomiting, and the likelihood of harm when antagonism was omitted. ⋯ A train-of-four ratio of > or = 0.9 is now accepted as the index of adequate recovery of neuromuscular function. Applying this new definition, residual paralysis becomes a frequent adverse side-effect. Neuromuscular recovery should therefore be routinely monitored in ambulatory patients and residual paralysis prevented by reversing neuromuscular block.
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Neuromuscular blocking agents are used as adjuvants in day case anaesthesia to facilitate tracheal intubation and/or surgery. Although the majority of day case procedures are performed without the use of neuromuscular blocking agents, there are procedures, such as laparoscopic surgery, microsurgery, open eye surgery, some ear, nose and throat procedures and some paediatric procedures, which may require neuromuscular blockade. The characteristics of an ideal neuromuscular blocking agent for day case surgery are a short onset, a short clinical duration and a short recovery time, with or without reversal. ⋯ This paper reviews the neuromuscular blocking agents currently available and used, such as succinylcholine and mivacurium, low doses of an intermediate-acting neuromuscular block, such as rocuronium and the recently introduced rapacuronium. Their advantages and disadvantages are described and discussed, with special reference to the needs of day case surgery. Rapacuronium offers certain benefits compared with the currently available neuromuscular blocking agents for day care anaesthesia.
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The need for a rapid-acting non-depolarizing neuromuscular blocking agent with a short duration of action resulted in the synthesis of rapacuronium. The onset of maximum block with rapacuronium occurs in 60-90 s with doses of 1.5-2.5 mg kg-1 with a duration of clinical relaxation of 15-30 min. ⋯ The main drawbacks of rapacuronium are the occurrence of dose-related pulmonary side-effects (increased airway pressure and/or overt bronchospasm) and hypotension and tachycardia. The cause of pulmonary side-effects is not certain but these have been serious enough to make its worldwide introduction doubtful.
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Eur J Anaesthesiol Suppl · Jan 2001
A practical clinical approach to management of the difficult airway.
Difficult airway management represents a challenge in anaesthesia. In the last decades airway difficulty awareness has improved as a result of better anticipation and decision-making. Airway algorithms and protocols have a more prominent role in training and in clinical anaesthesia practice. ⋯ Clinicians should become familiar with this equipment and techniques by using them on a regular basis in elective cases. The instruments available must be selected by the characteristics of the patient population, the local circumstances and the experience of the anaesthesiologist. The aim of this paper is to provide some practical guidelines with respect to airway difficulty predictors and airway instrument choice.
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Eur J Anaesthesiol Suppl · Jan 2001
An approach to quality management in anaesthesia: a focus on perioperative care and outcome.
Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. ⋯ Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's 'plan-do-check-act cycle' has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.