Anesthesiology clinics of North America
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Ambulatory surgery is increasing at unprecedented rates with more complex procedures being performed. This article reviews the benefits of the use of regional anesthesia during ambulatory surgeries. Regional anesthesia, by putting the anesthetic at the surgical site, provides ideal conditions for ambulatory surgery and provides a smooth, predictable post-operative course.
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The practice of administration of labor analgesia has undergone dramatic changes this decade. This is largely attributable to unparalleled interest in the field by many dedicated and capable investigators around the world. Through their efforts, this decade has witnessed the introduction of new techniques (pencil point needles, CSE, PCEA, ultradilute epidural regimens) that have permitted us to come closer than ever to realizing the goal of complete relief from the pain and suffering of labor while safeguarding the well-being of mother and child and minimizing effects on the labor process. Neuraxial anesthetic techniques and modern multimodal analgesic approaches to postoperative pain relief now minimize the effects of cesarean delivery on maternal satisfaction and participation in the birth process.
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Anesthesiol Clin North America · Jun 2000
ReviewThe role of epidural anesthesia and analgesia in postoperative outcome.
There is increasing evidence to support the hypothesis that epidural anesthesia and analgesia (EAA) can improve surgical outcome by reducing postoperative morbidity and hastening recovery. Likely benefits include decreased incidence of cardiac complications in high-risk patients; lower incidence of pulmonary complications, specifically pneumonia, atelectasis, and hypoxemia in patients at risk for pulmonary complications; lower incidence of vascular graft occlusion after lower extremity revascularization; lower incidence of DVT and pulmonary embolus; suppression of the neuroendocrine stress response; and earlier return of gastrointestinal function. Nonetheless, large multicenter prospective randomized studies are required to more definitively assess the impact of EAA on morbidity and mortality, ICU time, length of hospitalization, and cost of healthcare.
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Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. ⋯ Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.
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In conclusion, major complications after neuraxial techniques are rare but can be devastating to the patient and the anesthesiologist. Prevention and management begin during the preoperative visit with a careful evaluation of the patient's medical history and appropriate preoperative discussion of the risks and benefits of the available anesthetic techniques. Alternative anesthetic techniques, such as peripheral regional techniques or general anesthesia, should be considered for patients at increased risk for neurologic complications following neuraxial block. ⋯ Efforts should also be made to decrease neural injury in the operating room through careful patient positioning. Postoperatively, patients must be followed closely to detect potentially treatable sources of neurologic injury, including expanding spinal hematoma or epidural abscess, constrictive dressings, improperly applied casts, and increased pressure on neurologically vulnerable sites. New neurologic deficits should be evaluated promptly by a neurologist, or neurosurgeon, to document formally the patient's evolving neurologic status, arrange further testing or intervention, and provide long-term follow-up.