Pub Date : 2011-01-01DOI: 10.1097/ASA.0b013e3182299d36
K. Candido
Learning Objectives: As a result of completing this activity, the participant will be able to Evaluate the use of spinal injections for the diagnosis and treatment of chronic pain Identify the complication rates associated with each respective approach to managing spinal pain using injection therapy Describe the advantages and disadvantages of the particulate and nonparticulate steroidal medications commonly used in injection techniques
{"title":"Spinal Injections for the Diagnosis and Treatment of Chronic Spinal Pain","authors":"K. Candido","doi":"10.1097/ASA.0b013e3182299d36","DOIUrl":"https://doi.org/10.1097/ASA.0b013e3182299d36","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Evaluate the use of spinal injections for the diagnosis and treatment of chronic pain Identify the complication rates associated with each respective approach to managing spinal pain using injection therapy Describe the advantages and disadvantages of the particulate and nonparticulate steroidal medications commonly used in injection techniques","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"39 1","pages":"13–22"},"PeriodicalIF":0.0,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e3182299d36","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62019274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-01-01DOI: 10.1097/ASA.0b013e318229b26e
A. Lockhart
Learning Objectives: As a result of completing this activity, the participant will be able to Understand how to accurately assess the monetary and manpower cost of anesthesia services, such as obstetric (OB) or trauma coverage, requested by a health care institution Understand how to successfully negotiate a financially viable contract with a health care institution for delivery of anesthesia services Be more adept in addressing practical and political issues related to the contractual delivery of anesthesia services in situations in which remuneration from patient billing alone is unlikely to adequately cover the cost of service delivery and the institution may be reluctant or unwilling to provide compensatory support or modification of the coverage expectations
{"title":"Compensation for Services: Developing a Strategy for Success","authors":"A. Lockhart","doi":"10.1097/ASA.0b013e318229b26e","DOIUrl":"https://doi.org/10.1097/ASA.0b013e318229b26e","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Understand how to accurately assess the monetary and manpower cost of anesthesia services, such as obstetric (OB) or trauma coverage, requested by a health care institution Understand how to successfully negotiate a financially viable contract with a health care institution for delivery of anesthesia services Be more adept in addressing practical and political issues related to the contractual delivery of anesthesia services in situations in which remuneration from patient billing alone is unlikely to adequately cover the cost of service delivery and the institution may be reluctant or unwilling to provide compensatory support or modification of the coverage expectations","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"39 1","pages":"99–105"},"PeriodicalIF":0.0,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e318229b26e","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62019758","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-01-01DOI: 10.1097/ASA.0B013E3182289308
K. Drasner
Continued reports of major and minor neurologic sequelae following central neuraxial blockade have renewed concern regarding the potential toxicity of currently available local anesthetic agents. These reports, along with the experimental literature, have led to modifications in clinical practice. This lecture will summarize some of this clinical experience and the experimental findings that form the basis of these modifications, with particular emphasis on the rational selection of a local anesthetic for short-duration outpatient spinal anesthesia. In addition, the lecture will review the issue of local anesthetic systemic toxicity, focusing on the recent development of lipid rescue for bupivacaine cardiotoxicity, and the extension of lipid resuscitation beyond cardiotoxicity, and beyond treatment of the local anesthetics.
{"title":"Local Anesthetic Toxicity: Optimal Management to Avoid Neurotoxic Injury and Treat Cardiac Arrest","authors":"K. Drasner","doi":"10.1097/ASA.0B013E3182289308","DOIUrl":"https://doi.org/10.1097/ASA.0B013E3182289308","url":null,"abstract":"Continued reports of major and minor neurologic sequelae following central neuraxial blockade have renewed concern regarding the potential toxicity of currently available local anesthetic agents. These reports, along with the experimental literature, have led to modifications in clinical practice. This lecture will summarize some of this clinical experience and the experimental findings that form the basis of these modifications, with particular emphasis on the rational selection of a local anesthetic for short-duration outpatient spinal anesthesia. In addition, the lecture will review the issue of local anesthetic systemic toxicity, focusing on the recent development of lipid rescue for bupivacaine cardiotoxicity, and the extension of lipid resuscitation beyond cardiotoxicity, and beyond treatment of the local anesthetics.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"39 1","pages":"33-40"},"PeriodicalIF":0.0,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E3182289308","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62019071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-01-01DOI: 10.1097/ASA.0B013E31822A10BC
B. Drenger, Sudheer K Jain
Learning Objectives: As a result of completing this activity, the participant will be able to Evaluate the risks, different approaches to anesthesia, outcome and anesthesia, motor evoked potentials, and anesthetic considerations, for patients undergoing endovascular stenting Describe the important role of transesophageal echocardiography in diagnosing abnormalities and guiding endovascular stenting procedures Discuss mechanisms of cerebrospinal fluid (CSF) pressure rise, indications and risks of CSF drainage, the risk of cerebral hemorrhage, and blood patch
{"title":"Anesthesia for Patients With Aortic Aneurysm Undergoing Endovascular Stenting","authors":"B. Drenger, Sudheer K Jain","doi":"10.1097/ASA.0B013E31822A10BC","DOIUrl":"https://doi.org/10.1097/ASA.0B013E31822A10BC","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Evaluate the risks, different approaches to anesthesia, outcome and anesthesia, motor evoked potentials, and anesthetic considerations, for patients undergoing endovascular stenting Describe the important role of transesophageal echocardiography in diagnosing abnormalities and guiding endovascular stenting procedures Discuss mechanisms of cerebrospinal fluid (CSF) pressure rise, indications and risks of CSF drainage, the risk of cerebral hemorrhage, and blood patch","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"39 1","pages":"41-49"},"PeriodicalIF":0.0,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E31822A10BC","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62019491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-01-01DOI: 10.1097/ASA.0b013e31822a1106
B. Parker
Learning Objectives: As a result of completing this activity, the participant will be able to Assess the operational similarities between the operating room and hospital throughput List barriers that exist for hospital throughput and how these issues can affect both the operating room and postanesthesia care unit Apply strategies and operational techniques for improving overall hospital throughput and efficiency and to monitor implementation success Evaluate the options for presenting and displaying institutional throughput and quality data using business intelligence techniques Describe the value of using a ‘‘dashboard’’ for displaying relevant hospital data that can be managed to improve operational efficiencies
{"title":"Leveraging Operating Room Experience to Improve Hospital Throughput and Quality","authors":"B. Parker","doi":"10.1097/ASA.0b013e31822a1106","DOIUrl":"https://doi.org/10.1097/ASA.0b013e31822a1106","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Assess the operational similarities between the operating room and hospital throughput List barriers that exist for hospital throughput and how these issues can affect both the operating room and postanesthesia care unit Apply strategies and operational techniques for improving overall hospital throughput and efficiency and to monitor implementation success Evaluate the options for presenting and displaying institutional throughput and quality data using business intelligence techniques Describe the value of using a ‘‘dashboard’’ for displaying relevant hospital data that can be managed to improve operational efficiencies","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"39 1","pages":"120–125"},"PeriodicalIF":0.0,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e31822a1106","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62019616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2010-01-01DOI: 10.1097/ASA.0B013E3181EAE432
Susan S. Yoo, Linda L. Liu
Back decades ago, the coagulation cascade was taught in terms of 2 pathways, the intrinsic versus the extrinsic. Figure 1 shows a very simplified version of the proposed waterfall/ cascade model of the coagulation system. Unfortunately, as we started to understand more about the coagulation system, it became more and more complex. Many of the enzymes were found to be cofactors or were precursors to the active form. We also found that the 2 pathways were not completely separate in function. They appeared to be an intertwined system where modulation of one arm may or may not affect the second arm. The modern view of coagulation is to actually look at the coagulation system as a series of steps, 1) initiation, 2) amplification, and 3) propagation, as opposed to distinct pathways, (1) but the old 2 pathway model is still beneficial in terms of helping us understand what abnormal coagulation tests mean. This chapter will exam some causes of abnormal coagulation in the perioperative period and discuss agents that are used to modulate the coagulation system.
{"title":"Coagulation Abnormalities Made Easy","authors":"Susan S. Yoo, Linda L. Liu","doi":"10.1097/ASA.0B013E3181EAE432","DOIUrl":"https://doi.org/10.1097/ASA.0B013E3181EAE432","url":null,"abstract":"Back decades ago, the coagulation cascade was taught in terms of 2 pathways, the intrinsic versus the extrinsic. Figure 1 shows a very simplified version of the proposed waterfall/ cascade model of the coagulation system. Unfortunately, as we started to understand more about the coagulation system, it became more and more complex. Many of the enzymes were found to be cofactors or were precursors to the active form. We also found that the 2 pathways were not completely separate in function. They appeared to be an intertwined system where modulation of one arm may or may not affect the second arm. The modern view of coagulation is to actually look at the coagulation system as a series of steps, 1) initiation, 2) amplification, and 3) propagation, as opposed to distinct pathways, (1) but the old 2 pathway model is still beneficial in terms of helping us understand what abnormal coagulation tests mean. This chapter will exam some causes of abnormal coagulation in the perioperative period and discuss agents that are used to modulate the coagulation system.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"38 1","pages":"128-133"},"PeriodicalIF":0.0,"publicationDate":"2010-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E3181EAE432","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62018068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2010-01-01DOI: 10.1097/ASA.0B013E3181FF883E
R. Flick
Advances in the care of childhood conditions have resulted in the need for those previously not familiar with many of these problems to add them to their encyclopedia of knowledge. When considering this topic, one could reach broadly and include discussions of a variety of typical childhood diseases that increasingly persist into adulthood. This list includes such conditions as cerebral palsy, metabolic disorders, cystic fibrosis (CF), congenital heart disease (CHD), sickle cell anemia, muscular dystrophies and myopathies, as well as many of the childhood cancers that may leave both physical and psychological scars even when completely cured. Therefore, this review is limited to topics most relevant to the day-to-day practice of anesthesiology in the ‘‘real world’’ setting. Specifically, it will focus on the adult with repaired or palliated CHD, the adult with CF, and the increasingly common adult with a myopathy or dystrophy such as Duchenne or Becker. There are an infinite number of congenital disorders, chromosomal abnormalities, malformations, associations, and defects that even those of us devoted to tertiary pediatric anesthesia cannot possibly commit to memory. For those patients there are excellent resources that can provide focused information to assist in the anesthetic care. Although in everyday practice there is a tendency to focus on the concrete or nuts and bolts of the care of patients, it is important to provide a foundation for the discussion of the adult with a pediatric disease. By definition these ‘‘children’’ have chronic conditions that have required that they be involved repeatedly with the healthcare system; both as surgical and medical patients. As a consequence, they are very savvy as to the system and how to make it work best for them. They also have very clear preferences and are active participants in decisions regarding their healthcare management. Even though they are now young adults they are frequently accompanied by parents who also have an enormous amount of experience within the healthcare setting. To make the care of these patients and their families with success, it is critical to keep in mind the following: Often the patient and family know more about the rare disease that they have than you do. Two things are helpful: (1) Take a moment to read about the disorder to gain a basic familiarity with it here are excellent books and web sites that are helpful. (2) Admit to the family and the patient that this is a disorder that is not common in your practice. Patients and families will often test you to find out if you know anything about the rare condition. Having a fundamental knowledge and admitting the limits of that knowledge will be reassuring to the patient and family.
{"title":"Grown Ups With Pediatric Diseases: Your Pediatric Anesthesiologist to the Rescue!","authors":"R. Flick","doi":"10.1097/ASA.0B013E3181FF883E","DOIUrl":"https://doi.org/10.1097/ASA.0B013E3181FF883E","url":null,"abstract":"Advances in the care of childhood conditions have resulted in the need for those previously not familiar with many of these problems to add them to their encyclopedia of knowledge. When considering this topic, one could reach broadly and include discussions of a variety of typical childhood diseases that increasingly persist into adulthood. This list includes such conditions as cerebral palsy, metabolic disorders, cystic fibrosis (CF), congenital heart disease (CHD), sickle cell anemia, muscular dystrophies and myopathies, as well as many of the childhood cancers that may leave both physical and psychological scars even when completely cured. Therefore, this review is limited to topics most relevant to the day-to-day practice of anesthesiology in the ‘‘real world’’ setting. Specifically, it will focus on the adult with repaired or palliated CHD, the adult with CF, and the increasingly common adult with a myopathy or dystrophy such as Duchenne or Becker. There are an infinite number of congenital disorders, chromosomal abnormalities, malformations, associations, and defects that even those of us devoted to tertiary pediatric anesthesia cannot possibly commit to memory. For those patients there are excellent resources that can provide focused information to assist in the anesthetic care. Although in everyday practice there is a tendency to focus on the concrete or nuts and bolts of the care of patients, it is important to provide a foundation for the discussion of the adult with a pediatric disease. By definition these ‘‘children’’ have chronic conditions that have required that they be involved repeatedly with the healthcare system; both as surgical and medical patients. As a consequence, they are very savvy as to the system and how to make it work best for them. They also have very clear preferences and are active participants in decisions regarding their healthcare management. Even though they are now young adults they are frequently accompanied by parents who also have an enormous amount of experience within the healthcare setting. To make the care of these patients and their families with success, it is critical to keep in mind the following: Often the patient and family know more about the rare disease that they have than you do. Two things are helpful: (1) Take a moment to read about the disorder to gain a basic familiarity with it here are excellent books and web sites that are helpful. (2) Admit to the family and the patient that this is a disorder that is not common in your practice. Patients and families will often test you to find out if you know anything about the rare condition. Having a fundamental knowledge and admitting the limits of that knowledge will be reassuring to the patient and family.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"38 1","pages":"55-62"},"PeriodicalIF":0.0,"publicationDate":"2010-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E3181FF883E","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62018536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2010-01-01DOI: 10.1097/ASA.0B013E3181EAE604
B. Bucklin
Estimates suggest that 8-10% of parturients are morbidly obese. The care of these women is particularly challenging because coexisting disease(s) often complicate(s) obstetric and anesthetic management. Although there are no pregnancy-specific definitions of obesity, for purposes of this review we will consider pregnant women obese when the body mass index (BMI) is greater than 30 kg/m. Morbid obesity is typically described as a BMI greater than 40 kg/m.
{"title":"Anesthetic Management of the Morbidly Obese Parturient","authors":"B. Bucklin","doi":"10.1097/ASA.0B013E3181EAE604","DOIUrl":"https://doi.org/10.1097/ASA.0B013E3181EAE604","url":null,"abstract":"Estimates suggest that 8-10% of parturients are morbidly obese. The care of these women is particularly challenging because coexisting disease(s) often complicate(s) obstetric and anesthetic management. Although there are no pregnancy-specific definitions of obesity, for purposes of this review we will consider pregnant women obese when the body mass index (BMI) is greater than 30 kg/m. Morbid obesity is typically described as a BMI greater than 40 kg/m.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"38 1","pages":"16-22"},"PeriodicalIF":0.0,"publicationDate":"2010-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E3181EAE604","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62018171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2010-01-01DOI: 10.1097/ASA.0B013E3181EAE211
M. Cobas, T. Smaka, D. Lubarsky
Cardiovascular Changes Gelman et al. established the basis of our understanding of the pathophysiology of hemodynamic changes that occur with aortic clamping and unclamping. Aortic cross clamping increases mean arterial pressure and systemic vascular resistance (SVR) up to 50%. These sudden increases are due to an increase in mechanical afterload, activation of renin, and release of catecholamines, prostaglandins, and other vasoconstrictors. This increase in SVR causes an initial reflexive decrease in cardiac output (see Supplemental Digital Content 1, http://links.lww.com/ASA/A1). Some of the initial changes in hemodynamics associated with cross clamping can be offset by the sympathectomy caused by a thoracic epidural or with boluses of a vasodilator administered immediately before placement of the clamp. Shortacting pharmacologic agents (e.g., 0.3-0.7 mcg/kg of nitroprusside, 80-200 mcg of nitroglycerin or 200-600 mcg nicardipine) offset the mechanical effect of cross clamping, allowing the body to adapt. Preload changes are more variable than changes in SVR. Higher central venous and pulmonary artery occlusion pressures occur with higher clamp placement due to central redistribution of blood. In the patient with coronary disease, nitrate therapy during cross clamp will not necessarily prevent wall motion abnormalities, and care should be exercised when using any vasodilator so that perfusion pressure below the aortic cross clamp remains sufficient to avoid visceral/spinal cord ischemia. We will allow a systolic blood pressure (SBP) as high as 180-200 mm Hg provided there is no contraindication and the surgeon has acceptable operating conditions. Relative hypotension (less than 20% below baseline mean arterial pressure) probably should be avoided unless other means, such as shunts, are used to provide perfusion below the clamp. The level of clamping and the chronicity of occlusive disease can dramatically affect the hemodynamic response. The hemodynamic response is greater when the clamp is more proximal along the aorta (proximal descending thoracic aorta 4 supraceliac 4 suprarenal 4 infrarenal). There is an even smaller hemodynamic response when
{"title":"Perioperative Management of the Patient Undergoing Abdominal Aortic Surgery","authors":"M. Cobas, T. Smaka, D. Lubarsky","doi":"10.1097/ASA.0B013E3181EAE211","DOIUrl":"https://doi.org/10.1097/ASA.0B013E3181EAE211","url":null,"abstract":"Cardiovascular Changes Gelman et al. established the basis of our understanding of the pathophysiology of hemodynamic changes that occur with aortic clamping and unclamping. Aortic cross clamping increases mean arterial pressure and systemic vascular resistance (SVR) up to 50%. These sudden increases are due to an increase in mechanical afterload, activation of renin, and release of catecholamines, prostaglandins, and other vasoconstrictors. This increase in SVR causes an initial reflexive decrease in cardiac output (see Supplemental Digital Content 1, http://links.lww.com/ASA/A1). Some of the initial changes in hemodynamics associated with cross clamping can be offset by the sympathectomy caused by a thoracic epidural or with boluses of a vasodilator administered immediately before placement of the clamp. Shortacting pharmacologic agents (e.g., 0.3-0.7 mcg/kg of nitroprusside, 80-200 mcg of nitroglycerin or 200-600 mcg nicardipine) offset the mechanical effect of cross clamping, allowing the body to adapt. Preload changes are more variable than changes in SVR. Higher central venous and pulmonary artery occlusion pressures occur with higher clamp placement due to central redistribution of blood. In the patient with coronary disease, nitrate therapy during cross clamp will not necessarily prevent wall motion abnormalities, and care should be exercised when using any vasodilator so that perfusion pressure below the aortic cross clamp remains sufficient to avoid visceral/spinal cord ischemia. We will allow a systolic blood pressure (SBP) as high as 180-200 mm Hg provided there is no contraindication and the surgeon has acceptable operating conditions. Relative hypotension (less than 20% below baseline mean arterial pressure) probably should be avoided unless other means, such as shunts, are used to provide perfusion below the clamp. The level of clamping and the chronicity of occlusive disease can dramatically affect the hemodynamic response. The hemodynamic response is greater when the clamp is more proximal along the aorta (proximal descending thoracic aorta 4 supraceliac 4 suprarenal 4 infrarenal). There is an even smaller hemodynamic response when","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"38 1","pages":"23-29"},"PeriodicalIF":0.0,"publicationDate":"2010-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0B013E3181EAE211","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017944","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2010-01-01DOI: 10.1097/ASA.0b013e3181e9561f
T. Brennan
Progress in postoperative pain management decreases morbidity after surgery. To advance patient care, reduce perioperative morbidity, and decrease healthcare costs, it is critical that we improve acute postoperative pain management. Our armamentarium of drugs for acute pain management has been limited to opioids, controlled delivery of local anesthetics, and nonsteroidal antiinflammatory drugs or acetaminophen. For acute pain management, we operate using guidelines from the early 1990s that reinforced the generous use of opioids for acute pain even though effective dosing is limited by deleterious side effects. Anesthesia-based acute pain services popularized continuous epidural analgesia, which controls pain better during activities and continuous regional techniques for specific surgeries. If the 1990s assured us opioids should be used with confidence, the last 5 years has demanded efficacious alternatives to opioids with fewer side effects and, perhaps, improved outcome. This is in contrast to patients with rheumatoid arthritis who may be treated with drugs that block the action of inflammatory mediators such as tumor necrosis factor or interleukin-1 (IL-1). With increasing new knowledge and techniques come important opportunities and challenges for developing insights into the causes, mechanisms, and treatment of human disease. For anesthesiologists, we have an opportunity to treat surgery and trauma as a disease, and this requires investigation into the pathological processes that occur in the perioperative period. One component of the pathophysiology in surgery is acute postoperative pain. Our long-term goal will be to eliminate postoperative pain. This will require that we develop a better understanding of the mechanisms for surgical pain and prepare to use recent discoveries in biomedical research.
{"title":"Acute Pain: Pathophysiology and Clinical Implications","authors":"T. Brennan","doi":"10.1097/ASA.0b013e3181e9561f","DOIUrl":"https://doi.org/10.1097/ASA.0b013e3181e9561f","url":null,"abstract":"Progress in postoperative pain management decreases morbidity after surgery. To advance patient care, reduce perioperative morbidity, and decrease healthcare costs, it is critical that we improve acute postoperative pain management. Our armamentarium of drugs for acute pain management has been limited to opioids, controlled delivery of local anesthetics, and nonsteroidal antiinflammatory drugs or acetaminophen. For acute pain management, we operate using guidelines from the early 1990s that reinforced the generous use of opioids for acute pain even though effective dosing is limited by deleterious side effects. Anesthesia-based acute pain services popularized continuous epidural analgesia, which controls pain better during activities and continuous regional techniques for specific surgeries. If the 1990s assured us opioids should be used with confidence, the last 5 years has demanded efficacious alternatives to opioids with fewer side effects and, perhaps, improved outcome. This is in contrast to patients with rheumatoid arthritis who may be treated with drugs that block the action of inflammatory mediators such as tumor necrosis factor or interleukin-1 (IL-1). With increasing new knowledge and techniques come important opportunities and challenges for developing insights into the causes, mechanisms, and treatment of human disease. For anesthesiologists, we have an opportunity to treat surgery and trauma as a disease, and this requires investigation into the pathological processes that occur in the perioperative period. One component of the pathophysiology in surgery is acute postoperative pain. Our long-term goal will be to eliminate postoperative pain. This will require that we develop a better understanding of the mechanisms for surgical pain and prepare to use recent discoveries in biomedical research.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"38 1","pages":"8–15"},"PeriodicalIF":0.0,"publicationDate":"2010-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e3181e9561f","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62018337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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