Acta chirurgica Scandinavica. Supplementum
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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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Postoperative pulmonary complications are not uncommon, and the factors that contribute to lung dysfunction are well documented. Postoperative pain, spasm, and paralysis are all known to reduce lung function, although relief of pain does not completely restore function. Rather, diaphragmatic dysfunction has been found to persist even with adequate pain relief. ⋯ Muscle paralysis can also create or contribute to atelectasis. Microthromboembolism impedes perfusion distribution, adding to the other causes of a ventilation-perfusion mismatch. Different anesthetic techniques and intraoperative management may help prevent or reduce the incidence of postoperative lung complications.
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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.
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This brief review presents an update of studies on postoperative fatigue and convalescence and the way in which they are affected by anesthetic technique. Development of postoperative fatigue is related to the degree of surgical trauma, but not to general anesthesia, and it cannot be predicted from age, sex, duration of surgery, or preoperative assessment of various nutritional parameters. Postoperative fatigue correlates with deterioration in nutritional status and impaired adaptability of heart rate to orthostatic stress and bicycle exercise. ⋯ Pain relief with regional anesthetics does not improve postoperative fatigue after abdominal surgery; however, no studies are available that evaluate the effects of regional analgesia with concomitant inhibition of the stress response. Controlled studies suggest that the use of regional anesthesia with local anesthetics reduces duration of hospitalization and time to ambulation. Further studies are needed to define the relative roles of immobilization, impaired nutritional intake, and surgical stress response in the pathogenesis of postoperative fatigue.
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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.