Anesthesiology clinics of North America
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Spinal anesthesia can be used effectively and efficiently for a variety of cases in both the inpatient and the ambulatory surgery setting. Choice of agent, dose, distribution, use of adjuncts, and occasionally the use of continuous spinal anesthesia can tailor the spinal anesthetic to a specific type and duration of surgery. Although spinal anesthesia is extremely safe, adherence of new guidelines for patients receiving anticoagulant drugs, LMWH in particular, may minimize the risk of neurologic injury from spinal bleeding. ⋯ Spinal agents with long-acting analgesic properties that do not produce sensorimotor deficits may go beyond the immediate perioperative period and relieve postoperative pain. Currently there is controversy surrounding the use of spinal lidocaine and the occurrence of TNS, especially in the outpatient setting. The prudent use of small-dose bupivacaine and possibly procaine may reduce this risk, further supporting the use of spinal anesthesia for ambulatory as well as inpatient surgical procedures.
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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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Anesthesiologists have become increasingly involved with the management of chronic pain patients in the operating room, on the surgical floor, and in the outpatient pain facility setting (often interdisciplinary). Based upon the authors' practice of regional anesthesia, the most specific contribution to chronic pain management arguably remains the practice of diagnostic, prognostic, and therapeutic injections of the neuraxis, peripheral nerves, and the autonomic nervous system.
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Lower extremity nerve blocks have not become as popular as upper extremity blocks for anesthesia; however, the use of lower extremity nerve blocks will become more widespread, as teaching programs are now providing more regional anesthesia experiences for their trainees so that the anesthesia provider will have the familiarity to use these blocks. To increase the enthusiasm among our surgical colleagues, we must begin to use these blocks for surgery, and if the block must be supplemented with local anesthetic or a light general anesthetic, we must educate them that the block is not a failure but a success, as it will provide analgesia after surgery in a method of multimodal pain control. ⋯ Because the block may be placed in an induction room, there is no induction or emergence in the operating room. Patients may be discharged without the need for pain medications, thus lowering the incidence of nausea postoperatively and decreasing PACU and discharge times.
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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.