The Surgical clinics of North America
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Surg. Clin. North Am. · Jun 1999
ReviewSuperior vena cava syndrome. Experience with endovascular stents and surgical therapy.
Superior vena cava (SVC) syndrome is a serious complication of benign and malignant diseases. Benign causes may be increasing because of the increased use of central venous cannulation. Modern surgical therapy is durable with a few complications. ⋯ Endovascular techniques present a new treatment option for these patients, and uses a combination of thrombolysis, angioplasty, and intravascular stents. Short-term results are excellent with relatively rapid patient recovery. Further research is needed to elucidate the long-term results of endovascular treatment and to find its role in benign and malignant disease.
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Optimizing postoperative pain control is the key to further advancement in the field of ambulatory anesthesia. The current situation in postoperative pain management indicates room for improvement, especially in the area of patient education and the development of individualized discharge analgesic packages. ⋯ Preoperative administration of analgesia would decrease the intraoperative analgesic requirement, which may lead to a smooth and rapid recovery. Finally, new, portable analgesic delivery systems are under investigation and may prove to be the method of choice for future postoperative pain, management in ambulatory anesthesia.
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In appropriately selected patients, PCA safely provides analgesia superior to that obtained with traditional IM prn opioid administration; however, to date, no compelling evidence shows that PCA is associated with a reduction in morbidity or a more rapid recovery. PCA is deceptively easy to prescribe; however, to use it effectively and safely requires experience, frequent patient assessment, and a skilled and knowledgeable nursing staff.
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The discovery of opioid receptors and the subsequent development of the technique of epidural and intrathecal opioid administration are undoubtedly two of the most significant advances in pain management in recent decades. The use of spinal opioids is widespread and increasing. The technique is used widely to treat intraoperative, postoperative, traumatic, obstetric, chronic, and cancer pain. ⋯ Although rare, respiratory depression continues to be a major problem of the technique. None of the currently available opioids is completely safe; however, extensive international experience has shown that patients receiving spinal opioids for postoperative analgesia can be safely nursed on regular wards, provided that trained personnel and appropriate guidelines are available. The importance of a good acute pain service to provide the safe and effective use of spinal opioids cannot be overemphasized.
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Opioids are the most commonly used medication for patients with acute pain. Morphine is the prototype with which all other opioids are compared. Synthetic and semisynthetic derivatives of morphine have unique properties, allowing for the use of a larger selection of medication. An understanding of the mechanisms of action, adverse effects, and routes of administration of the various potent opioids is important for good postoperative pain management.