Articles: surgery.
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Randomized Controlled Trial Clinical Trial
Satisfaction with epidural and intravenous patient-controlled analgesia.
Postoperative intravenous (i.v.) versus epidural morphine patient-controlled analgesia (PCA) were compared regarding maintenance of initial PCA route, pain levels, side effects, and levels of satisfaction. Additionally, the role of preoperative attitudinal expectations in predicting postoperative levels of satisfaction with pain management as well as maintenance of initial PCA route was evaluated. ⋯ Both techniques, i.v. and epidural PCA, result in high levels of satisfaction. Satisfaction with PCA can be accurately predicted in nearly three of four patients based on initial PCA route and preoperative attitudes. Additionally, maintaining the initial treatment plan can be accurately predicted based on age and preoperative attitudes. Patient expectations about pain relief should be addressed preoperatively, particularly with younger patients, for optimal results.
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Recently, there has been considerable interest in regional anaesthetic techniques, particularly in peripheral nerve blockade, for orthopaedic limb surgery. Many traditional nerve-block techniques have been significantly modified to improve their role in both in-patient and out-patient surgery. The introduction of long-acting local anaesthetic with a better safety profile as well as better equipment for continuous nerve blockade has further increased the use of such techniques in the provision of postoperative analgesia. The recent developments described in this review are likely to result in wider use of these techniques in years to come.
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The recent introduction of oral COX-2 selective NSAIDs with potential for perioperative use, and the ongoing development of intravenous formulations, stimulated a systemic review of efficacy, side effects, and regulatory issues related to ketorolac for management of postoperative analgesia. ⋯ Ketorolac should be administered at the lowest dose necessary. Analgesics that provide effective analgesia with minimal adverse effects are needed.
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To measure airway pressures during closed system suctioning with the ventilator set to three differing modes of ventilation. ⋯ Closed system suctioning in volume control ventilation may result in elevations of end-expiratory pressure following catheter insertion and subatmospheric airway pressures during suctioning. Pressure control ventilation produces less elevation of end-expiratory pressure following catheter insertion and is less likely to be associated with subatmospheric airway pressures during suctioning. CPAP/pressure support has no effect on end-expiratory pressure following catheter insertion and subatmospheric airway pressures are largely avoided during suctioning.
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Surgical trauma and anaesthetics may cause immune suppression, predisposing patients to postoperative infections. Furthermore, stress such as surgery and pain per se is associated with immune suppression which, in animal models, leads to an increased susceptibility to infection and tumour spread. Thus, by modulating the neurohumoral stress response, anaesthesia may indirectly affect the immune system of surgical patients. ⋯ There is a striking body of evidence that long-term exposure to certain sedatives is paralleled by infectious complications. On the other hand, anti-inflammatory effects of anaesthetics may be therapeutically beneficial in distinct situations such as those involving ischaemia/reperfusion injury or the systemic inflammatory response syndrome. Consequently, sedatives should be administered with careful regard to their respective potential immunomodulatory properties, the clinical situation, and the immunity status of the critically ill patient.