Seminars in anesthesia最新文献

Gainsharing is a pay for performance model particularly applicable to the anesthesia group-hospital relationship. Recent regulatory action combined with the popularity of the pay for performance (“P4P”) movement signal this is the time to consider potential ways to increase income through gainsharing deals.

Dexmedetomidine is an α-2 adrenoreceptor agonist which has displayed neuroprotective properties in a variety of in vitro and in vivo laboratory studies; however, the mechanism of neuroprotection remains unclear. Modulation of pathways leading to excitatory cell death and apoptosis are likely to be involved, although there is evidence for and against these theories. Randomized controlled clinical trials in humans are needed to ascertain the efficacy of dexmedetomidine as a neuroprotectant in humans before its clinical use as a neuroprotectant can be recommended.

Bariatric surgery has become a popular treatment for morbid obesity. The type of surgery could be either a gastric resection with Roux-en-Y construction or an adjustable gastric banding. Although still performed as an open procedure, bariatric surgery is now usually performed laparoscopically. The pathophysiology of morbid obesity puts the patient at risk for major respiratory and cardiovascular adverse events. To ameliorate these risks, the α₂-adrenoreceptor agonist dexmedetomidine was introduced for the anesthetic and postoperative management of these patients. In one center, over 2000 bariatric procedures have now been performed safely using the perioperative administration of dexmedetomidine. Dexmedetomidine has little effect on ventilation is cardioprotective and neuroprotective and allows for a hemodynamically very stable course, while reducing the need for opioids and inhalational agents. This results in less respiratory depression and airway compromise, less nausea and vomiting, better intestinal function, and potentially, a day surgery (less than 24 hour admission) procedure.

The awake fiberoptic intubation (AFI) is an important part of the anesthesiologist’s armamentarium. As well as being technically challenging, it is also uncomfortable and stressful for all involved. We discuss the use of an alpha-2 agonist, dexmedetomidine, to help the clinician and patient through this procedure. The advantages of dexmedetomidine are that it produces a unique “Cooperative Sedation,” which reduces discomfort in the patient and assists in the topicalization of the airway. Most importantly, dexmedetomidine does not produce significant respiratory depression, so the airway may be secured in the safest manner possible. We discuss the history of sedation for AFI, other medications, as well as guidelines and pitfalls in the use of dexmedetomidine.

Many additives to local anesthetics to prolong the duration of peripheral nerve blocks have been investigated throughout the years. Clonidine, an alpha-2 agonist, has shown efficacy with all local anesthetics in a variety of peripheral nerve block techniques. In vitro and in vivo laboratory animal studies indicate a direct action on the peripheral nerve by clonidine, which is not mediated via the alpha-2 receptor. Dexmedetomidine (Precedex^®) is a newer alpha-2 agonist that has shown some promise in a limited number of regional anesthesia investigations. The following article reviews the available clinical peripheral nerve block studies using clonidine, laboratory animal in vitro and in vivo studies on the effect of perineural clonidine, and studies using dexmedetomidine in regional anesthesia.

Dexmedetomidine (Precedex^®) is an α₂-adrenergic agonist which is currently FDA-approved for the short-term (less than 24 hours) sedation of adult ICU patients. Its clinical effects include sedation, anxiolysis, analgesia, a decrease of the minimum alveolar concentration of inhalational anesthetic agents, blunting of the sympathetic nervous response to surgery, and lowering of heart rate and blood pressure. These beneficial physiologic effects combined with its relatively low incidence of adverse hemodynamic and respiratory effects have led to its use in the pediatric-aged patient in various applications including sedation during mechanical ventilation, prevention of emergence agitation following general anesthesia with sevoflurane or desflurane, provision of procedural-sedation, and to prevent withdrawal following the prolonged use of opioids and benzodiazepines. The following article reviews the reports of the use of dexmedetomidine in pediatric patients including dosing regimens and adverse effects. Its potential applications in the practice of pediatric anesthesiology and critical care are explored.

Benzodiazepines and opioids are routinely used in the perioperative period and the intensive care unit (ICU) to prevent anxiety and pain. These agents have the potential for side effects that may worsen outcomes in critically ill patients. Alpha₂ agonists are increasingly being used as adjuvant therapeutic agents in the perioperative period because of their ability to block the sympathetic stress response, complete with their anesthetic and analgesic sparing properties, lack of respiratory depression, and low and predictable side effect profile. The recent approval of dexmedetomidine, a parentally administered alpha₂ agonist, provides an alternative to the conventional strategy of sedation and analgesia utilizing benzodiazepines and opiates. This state of the art review examines the physiological properties and uses of alpha₂ agonists, with emphasis on dexmedetomidine, in the perioperative period and in the ICU.

The safe delivery of an office-based anesthetic starts with the office set-up. The anesthesiologist preparing to provide services in the office setting needs to be aware of all the issues involved. It is his/her primary responsibility to ensure that the office provides as safe an environment as a hospital or a free-standing ambulatory surgery center. In this article, the considerations and requirements to accomplish this are discussed.