Acta chirurgica Scandinavica. Supplementum
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Acta Chir Scand Suppl · Jan 1989
Comparative StudyBeneficial effects on intraoperative and postoperative blood loss in total hip replacement when performed under lumbar epidural anesthesia. An explanatory study.
The effects of continuous lumbar epidural anesthesia and two types of general anesthesia on blood loss and hemodynamics during and after total hip replacement were compared in three groups of patients. Fourteen patients received local anesthetics via continuous lumbar epidural administration; 10 patients received inhalational anesthetics and breathed spontaneously after endotracheal intubation; and 14 received artificial ventilation after intubation and intermittent intravenous (i.v.) injections of pancuronium and fentanyl. The results documented that both intraoperative and postoperative blood losses were significantly reduced in patients subjected to total hip replacement under lumbar epidural anesthesia as compared with the patients receiving the two general anesthetic techniques. ⋯ Postoperatively, the hemodynamics of the general anesthesia groups were similar, and no differences in blood loss occurred. Continuous' epidural anesthesia can be viewed as a tool to achieve hypotensive anesthesia--notably on the venous side--for the purpose of minimizing blood loss. The reduction in blood loss associated with lumbar epidural anesthesia is beneficial in decreasing the hazard and cost of blood transfusion.
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In recent years hospitals have begun to institute special postoperative pain services staffed by anesthesia department personnel. The charter for such services is to provide the best and most appropriate postoperative analgesia for surgical patients, in particular for the increasing numbers of patients who, released from hospital soon after surgery, still require pain relief on an outpatient basis. This review focuses on the relative benefits and risks of the currently available options for postoperative pain relief: intramuscular (i.m.) and intravenous (i.v.) administration of narcotics; epidural or subarachnoid administration of narcotics and/or local anesthetics; and peripheral nerve blocks with local anesthetics. In terms of efficacy, cost, risk, and personnel requirements, the particular advantages of continuous analgesia techniques--including patient-controlled analgesia--are discussed.
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Gastrointestinal motility is normally inhibited for 2-3 days after abdominal surgery. The methods used for postoperative pain relief may themselves also influence gastrointestinal function. ⋯ Clinical studies show that epidural anesthesia does not delay gastric emptying or prolong intestinal transit time as much as parenteral and epidural opioids. Therefore, for postoperative pain relief after abdominal surgery, epidural anesthesia with local anesthetics seems the best alternative to avoid or minimize adverse effects on gastric emptying and intestinal motility.
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Acta Chir Scand Suppl · Jan 1989
ReviewThe stress response to surgery: release mechanisms and the modifying effect of pain relief.
This short review updates information on the release mechanisms of the systemic response to surgical injury and the modifying effect of pain relief. Initiation of the response is primarily due to afferent nerve impulses combined with release of humoral substances (such as prostaglandins, kinins, leukotrienes, interleukin-1, and tumor necrosis factor), while amplification factors include semi-starvation, infection, and hemorrhage. The relative role of the various signals in producing the complex injury response has not been finally determined, but the neural pathway is probably most important in releasing the classical endocrine catabolic response, while humoral factors are important for the hyperthermic response, changes in coagulation and fibrinolysis immunofunction, and capillary permeability. ⋯ Systemic opiate administration, as well as non-steroidal antiinflammatory drugs, exert only a small modifying effect on the response. Low-dose combined analgesic regimens may provide total pain relief, but exert no important effect on the stress response. In summary, pain alleviation itself may not necessarily lead to an important modification of the stress response, and a combined approach with inhibition of the neural and humoral release mechanisms is necessary for a pronounced inhibition or prevention of the response to surgical injury.
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Acta Chir Scand Suppl · Jan 1989
ReviewThe influence of anesthesia and postoperative analgesic management of lung function.
General anesthesia itself may influence postoperative lung function. It leads to a depression of the functional residual capacity, which, in combination with surgical trauma and postoperative pain, can provoke insufficient breathing, retention of bronchial secretions, and atelectasis. ⋯ After upper abdominal or thoracic surgery, postoperative epidural analgesia causes a significant increase of lung function as compared with systemic analgesia. The combination of regional anesthesia and general anesthesia intraoperatively appears to reduce lung function much less than general anesthesia alone.