Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2005
ReviewAdvantages and disadvantages of adrenaline in regional anaesthesia.
Adrenaline has been added to local anaesthetic solutions for more than a century. The aim has been to delay the absorption of the local anaesthetic drug and to prolong and enhance its anaesthetic effect, both in peripheral and central neuraxial blockades. ⋯ The main part of this chapter will therefore focus on the advantages and disadvantages of adrenaline in epidural analgesia. However, recent knowledge about adrenaline in peripheral blockade will also be covered, together with some pharmaceutical comments on the shelf-life of local anaesthetic mixtures containing adrenaline.
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Best Pract Res Clin Anaesthesiol · Jun 2005
ReviewThe pharmacokinetics of ropivacaine in hepatic and renal insufficiency.
In patients with chronic end-stage liver disease, the peak plasma concentrations of ropivacaine after a single intravenous ropivacaine dose are similar to those in healthy subjects. However, patients with end-stage liver disease have about a 60% lower mean ropivacaine clearance than healthy subjects and are thus expected to have over two-fold higher steady-state ropivacaine plasma concentrations during a continuous ropivacaine infusion. ⋯ However, uraemic patients have significantly higher alpha-1-acid glycoprotein plasma concentrations than non-uraemic patients, and the peak plasma concentrations of free ropivacaine (related to toxicity) are similar in both groups. The pharmacokinetics of intravenously administered ropivacaine in patients with renal insufficiency and the possibility of clinically significant (S)-2',6'-pipecoloxylidide metabolite accumulation during continuous or repeated ropivacaine administration in these patients remain to be clarified.
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Best Pract Res Clin Anaesthesiol · Jun 2005
ReviewClinical pharmacology and the use of articaine for local and regional anaesthesia.
Quicker onset and shorter elimination time favours (+/-) articaine as a short-acting local anaesthetic for regional anaesthesia in day-case settings, e.g. arthroscopy (shoulder, knee), hand and foot surgery, and dentistry, because patients treated with articaine will be 'drug free' more quickly than those who receive other local anaesthetics. Articaine diffuses better through soft tissue and bone than other local anaesthetics. The concentration of articaine in the alveolus of a tooth in the upper jaw after extraction was about 100 times higher than that in systemic circulation. ⋯ Intrinsic half-lives of articainic acid are: t1/2alpha 12 minutes, and t1/2beta 64 minutes (1 hour). In dentistry, articaine is the drug of choice in the vast majority of literature. In other regional anaesthesia techniques (intravenous regional anaesthesia, epidural, spinal and plexus blocks) there are not enough data to prove that (+/-) articaine is safer and more effective than the short-acting local anaesthetics lidocaine, (+/-) prilocaine or (+/-) mepivacaine.
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During the last 20 years, studies using continuous perioperative electrocardiogram (ECG) monitoring in patients at high risk for postoperative cardiac complications have revolutionized our understanding of the pathophysiology, circumstances, timing and possible prevention of perioperative ischemia and postoperative cardiac morbidity and mortality. The present review attempts to provide a comprehensive and practical summary of the current knowledge on perioperative myocardial ischemia. It starts with a description of the conventional definition of myocardial ischemia on exercise stress-testing and continues with a summary of the findings and insights collected from ambulatory Holter monitoring in non-surgical patients with coronary artery disease. It then recaps the variety of studies using perioperative ischemia monitoring to detail the concepts and controversies brought about by this type of monitoring, and tries to portray a general picture of the association of perioperative ischemia and postoperative cardiac complications-including myocardial infarction-and emphasize the importance of postoperative, not just intraoperative, ischemia monitoring.
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The use of epidural analgesia for labor continues to increase dramatically. It has been suggested that epidural analgesia increases the risk of cesarean section, operative vaginal delivery, and prolonged labor. ⋯ It may affect the incidence of forceps delivery, but it depends on the medications used. Epidural analgesia does prolong labor, although the clinical significance of this prolongation has not been shown.