Anesthesiology clinics of North America
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Anesthesiol Clin North America · Jun 2003
ReviewEffective analgesic modalities for ambulatory patients.
The introduction of government-mandated standards for pain management has focused our attention on postoperative pain. With the recent JACHO standards' for ambulatory surgery, it is imperative that all health care workers who care for these patients are familiar with appropriate pain management. Developments in our understanding of the pathophysiology of acute pain have further enhanced our ability to improve pain management for postoperative ambulatory patients. ⋯ Nonpharmacological intervention such as cold therapy or acupuncture may also be considered. The armanentarium for effective pain management has improved substantially over the past few years. The challenge is for health care workers to implement these therapies to obtain optimum pain management in ambulatory surgical patients.
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This article summarizes current guidelines in pediatric ambulatory anesthesia and surgery. The reader is provided with our department's current outpatient guidelines at Children's Hospital of Philadelphia and the rationale behind them. Whenever possible, the differences in anesthetic management for the freestanding surgicenter will be discussed. Appropriate patient and procedure selection, preoperative assessment, intraoperative and postoperative considerations, and protocols for follow-up are discussed.
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In summary, regional techniques offer significant advantages in the outpatient setting. They can avoid the side effects of nausea, vomiting, and pain that frequently delay discharge or cause admission. ⋯ Despite frequently requiring some additional time at the outset, regional techniques have consistently been shown to provide competitive discharge times and costs when compared with general anesthesia. They deserve a prominent place in outpatient surgery.
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In the current health care environment, anesthesia practitioners are frequently required to reevaluate their practice to be more efficient and cost-effective. Although IV induction with propofol and inhalational induction with sevoflurane are both suitable techniques for outpatients, patients prefer IV induction. Maintenance of anesthesia with the newer inhaled anesthetics (ie, desflurane and sevoflurane) provide for a rapid early recovery as compared with infusion of propofol (ie, TIVA), while allowing easy titratability of anesthetic depth. ⋯ Although clinical differences between desflurane and sevoflurane appear to be small, desflurane may be associated with faster emergence, particularly in elderly and morbidly obese patients. Balanced anesthesia with IV propofol induction and inhalation anesthesia with N2O for maintenance, and an LMA for airway management, may be an optimal technique for ambulatory surgery. Inhalational anesthesia may have an economic advantage over a TIVA technique.
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Anesthesiol Clin North America · Mar 2003
ReviewMechanisms and management of an incomplete epidural block for cesarean section.
Epidural blockade is an important option for anesthesia in parturients undergoing abdominal delivery. Despite the multiple benefits of this method, there is at least one significant downside--a relatively high occurrence of unsatisfactory anesthesia that requires intervention. Depending on the presumed mechanism of epidural block failure and other clinically relevant factors (e.g., timing of diagnosis, urgency of the procedure, and so forth), certain effective measures are recommended to successfully manage this demanding situation. ⋯ When inadequate epidural block becomes apparent during surgery there are limited alternatives. Depending on the origin and the pattern of inadequate anesthesia, options may include psychological support, supplementation with a variety of inhalational and intravenous agents, and local anesthetic infiltration. Induction of general anesthesia is typically left as a backup option, but must be strongly considered if the patient continues to have pain/discomfort.