Annales chirurgiae et gynaecologiae
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Narcotics have been shown to act selectively upon nociceptive synaptic junctions in laminae 1 and 2 of the dorsal horn of the spinal cord. Subarachnoid or epidural injection of narcotics can produce selective segmental analgesia of great intensity and prolonged duration that is free of motor or sympathetic blockade. However, poorly lipid-soluble drugs, such as morphine, that tend to linger in the water phase of the CSF may spread rostrally to involve opiate receptors in brain stem nuclei. ⋯ Obstetrical pain is less amenable to this approach. Effective and safe management of acute pain requires that the patients be under adequate surveillance to avoid the danger of insidious respiratory depression. Chronic malignant pain is well controlled by relatively small doses of narcotic, and these patients can be managed at home on a long-term basis.
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Sufficient placental blood flow is mandatory for the well-being of the fetus. The delicate balance between uterine perfusion pressure and uterine vascular resistance can be critically disturbed during epidural anaesthesia. Maternal hypotension is common when extensive block for Caesarean Section is used. ⋯ Epinephrine (less than or equal to 50 micrograms), added to the local anaesthetic, will not decrease IBF. IBF can be severely reduced in pregnancy-induced hypertension (PIH) since the fetus is chronically asphyxiated it is crucial to avoid any further decrease in IBF. Extensive sympathetic blockade (T8) using epidural analgesia (10 ml dose of 1.a.) has been shown to significantly (p less than 0.01) improve IBF in parturients with PIH by decreasing uteroplacental vascular resistance.
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The methods of providing postoperative analgesia by regional anaesthetic techniques with local anaesthetics are outlined. For the use of epidural analgesia, the techniques of inserting an epidural catheter at any level of the spine must be familiar. The block should be regional, restricted to the area of pain and effective at all times after its institution with a minimum of side effects. ⋯ A dose regimen for thoracic, abdominal, perineal and lower extremity pain is presented. Side effects of the epidural technique and ways to treat and avoid them are discussed. The intercostal nerve block for post-thoracotomy and upper abdominal pain is described with special reference to the recent development of the continuous technique with bupivacaine and the cryoanalgesia technique.
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The clinical course and outcome of 49 consecutive near-drowned patients is presented. All the immersions occurred in fresh water. 37 patients (76%) survived. All 28 patients who were conscious upon admission to hospital recovered fully. ⋯ Among unconscious patients, the non-survivors had on arrival an average lower rectal temperature than the survivors. The following factors during intensive care correlated with bad prognosis: low PaO2/FiO2, low serum protein concentration and disturbances in renal function. Furthermore, the findings of this study suggest that although a specific near-drowned patient has on admission most abnormal laboratory values, these do not predict his fate, but effective treatment has to be given.