Therapeutics and clinical risk management
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In recent years levobupivacaine, the pure S (-)-enantiomer of bupivacaine, emerged as a safer alternative for regional anesthesia than its racemic parent. It demonstrated less affinity and strength of depressant effects onto myocardial and central nervous vital centers in pharmacodynamic studies, and a superior pharmacokinetic profile. Clinically, levobupivacaine is well tolerated in a variety of regional anesthesia techniques both after bolus administration and continuous postoperative infusion. ⋯ In anesthesia and analgesia practice, levobupivacaine and bupivacaine produce comparable surgical sensory block with similar adverse side effects, and equal labor pain control with comparable maternal and fetal outcome. The equipotency of the two drugs has been recently questioned, prompting clinicians to increase the dose of levobupivacaine in an attempt to ensure adequate anesthesia and analgesia and offsetting, therefore, the advantages of less motor block with levobupivacaine. In this review we aim to discuss the pharmacological essentials of the safer profile of levobupivacaine, and analyze the evidence regarding the current clinical indications.
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Recent studies suggest that current fluid strategies may result in excessive administration of both fluids and electrolytes. Perioperative fluid administration is dictated by an algorithmic approach, taking account of pre-operative deficit, maintenance requirements, and extrapolated third space losses. Salt and water overload is associated with pulmonary edema, ileus, and delayed wound healing. ⋯ Should a "restricted" rather than a "liberal" perioperative fluid regimen be employed? It is arguable that prevailing fluid therapy is not evidence-based. Recent observations suggest that restraint in fluid administration correlates with better outcome. The development of a protocol-based fluid optimization program may help minimize the risk of perioperative fluid overload.