Sedation and regional anaesthesia in the adult patient

This review discusses sedation for regional anaesthesia in the adult population. The first section deals with general aspects of sedation and shows that the majority of patients receiving sedation for regional anaesthesia are satisfied and would choose it again. Methods of assessing the level of sedation are discussed with emphasis on clinical measures. The pharmacology of the drugs involved in sedation is discussed, with propofol and remifentanil appearing to be the combination of choice for sedation in regional anaesthesia. The techniques for administering sedation are discussed and replacement of the traditional repeated boluses or continuous infusion with pharmacokinetic and patient-controlled systems is supported. Patient satisfaction studies suggest that patient-controlled systems are preferre

Gabapentin and pregabalin for the acute post-operative pain management. A systematic-narrative review of the recent clinical evidences

Background: Gabapentin and pregabalin inhibit Ca2+ currents via high-voltage-activated channels containing the α2δ-1 subunit, reducing neurotransmitter release and attenuating the postsynaptic excitability. They are antiepileptic drugs successfully used also for the chronic pain treatment. A large number of clinical trials indicate that gabapentin and pregabalin could be effective as postoperative analgesics. This systematic-narrative review aims to analyse the most recent evidences regarding the effect of gabapentinoids on postoperative pain treatment. Methods: Medline, The Cochrane Library, EMBASE and CINHAL were searched for recent (2006-2009) randomized clinical trials (RCTs) of gabapentin-pregabalin for postoperative pain relief in adults. Quality of RCTs was evaluated according to Jadad method. Visual analogue scale (VAS), opioid consumption and side-effects (nausea, vomiting, dizziness and sedation) were considered the most important outcomes. Results: An overall of 22 gabapentin (1640 patients), 8 pregabalin (707 patients) RCTs and seven meta-analysis were involved in this review. Gabapentin provided better post-operative analgesia and rescue analgesics sparing than placebo in 6 of the 10 RCTs that administered only pre-emptive analgesia. Fourteen RCTs suggested that gabapentin did not reduce PONV when compared with placebo, clonidine or lornoxicam. Pregabalin provided better post-operative analgesia and rescue analgesics sparing than placebo in two of the three RCTs that evaluated the effects of pregabalin alone vs placebo. Four studies reported no pregabalin effects on preventing the PONV. Conclusion: Gabapentin and pregabalin reduce pain and opioid consumption after surgery in confront with placebo, but comparisons with other standard post-operative regimens are not sufficient. Gabapentin and pregabalin seem not to have any influence on the prevention of PONV

ANAESTHESIA AND PAIN MANAGEMENT IN COMPANION ANIMALS

In the last decades, pain management has become central to small animal practice. Alleviating pain is not only a professional obligation but also a key contributor to successful case outcomes. Although acute and maladaptive chronic pain management is now an established component of therapy, the development of new drugs, analgesic techniques and non-pharmacological modalities makes this a still evolving facet of small animals clinical practice. Intraperitoneal and intra-articular administration of analgesic drugs are two alternative, simple and low-cost techniques for perioperative pain management in small animal practice. Based on the results obtained in the first study of this PhD dissertation, intraperitoneal administration of local anesthetics provides effective post-operative pain relief in dogs undergoing major abdominal surgeries. Intraperitoneal ropivacaine, a longer lasting local anesthetic, provided an analgesic effect lasting up to 24 hours after the end of surgery. Its duration was longer than that of intraperitoneal lidocaine and this finding results in a decreased postoperative opioids requirement and in a more rapid food intake in recruited dogs. Results of the second study presented in this this PhD dissertation showed that preemptive intra-articular dexmedetomidine, alone or in combination with lidocaine, provided effective intraoperative analgesia in dogs undergoing arthroscopy; treatments also resulted in similar postoperative analgesic effects. In the third and fourth studies we moved to maladaptive chronic pain treatment, describing two new possible therapies for maladaptive chronic pain in dogs: a multimodal pharmacological management involving cannabidiol, a new therapeutic option in dogs affected by osteoarthritis, and the use of radiofrequency, an interventional and non-pharmacological technique, completely new in veterinary medicine. According to the results of our third study, a satisfactory pain and quality of life management was achieved in dogs receiving oral transmucosal cannabidiol oil in addition to a multimodal pharmacological approach for treatment of osteoarthritis-related pain in dogs. Combined with an anti-inflammatory drug, gabapentin and amitriptyline, cannabidiol appears to enhance osteoarthritic pain relief and quality of life improvement. Furthermore, its co-administration results useful in reducing the other administered drugs’ dosage, minimizing the severity and incidence of associated side effects. The high cannabidiol patient tolerability, the easy practicability and the paucity of adverse effects of oral transmucosal route of administration may represent potential benefits for long-term therapy. In the fourth study we focused on radiofrequency, whose long-term efficacy has been previously evaluated in a small group of dogs affected by maladaptive chronic pain. Although this study is an ongoing project and in the present form includes a small number of patients, in accordance with the obtained preliminary results, it seems that radiofrequency is an effective procedure that do not result in the development of serious adverse effects in dogs suffering of maladaptive chronic pain. In conclusion, this dissertation includes studies of different nature, involving different analgesic techniques for management of different types of pain in dogs, but the common thread is represented by the attempt to find new treatment options, in order to promote a proactive, preemptive and multimodal pain management in companion animals. The rationale behind this attempt is that using new pharmacological and non-pharmacological techniques, targeting multiple sites in pain pathways, minimize the potential for side effects associated with any single technique and provide a more effective pain management. Pain alleviation, and therefore animals welfare, is an ethical and medical duty and all the new techniques to reduce pain, stress and anxiety should be encouraged

Guidelines for day-case surgery 2019:Guidelines from the Association of Anaesthetists and the British Association of Day Surgery

Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.</p

Analgesia and side effects of the addition of 10 or 20 mu g fentanyl to articaine in spinal anesthesia for knee arthroscopy : a randomized and observer-blinded study

Objectives Articaine, a popular and rapidly acting local anesthetic in dentistry, has been also found to be beneficial in ambulatory spinal anesthesia. Analgesia in the intraoperative and immediate postoperative period may be further improved by adding fentanyl to the local anesthetic solution for spinal anesthesia. The aim was to evaluate dose-dependency of analgesia and side effects associated with intrathecal fentanyl additive to articaine for spinal anesthesia in knee arthroscopy patients. Methods In this randomized, observer- and patient-blinded study, 90 adult patients scheduled for elective ambulatory knee arthroscopy under spinal anesthesia were randomized into three groups: plain articaine 60 mg with saline (group AF0), articaine 60 mg with fentanyl 10 A mu g (group AF10) or 20 A mu g (group AF20) in a total volume of 1.9 ml. The blinded observer tested the sensory and the motor block, and performed telephone interviews on the first and seventh postoperative days. Results The median (IQR) duration of sensory block at the dermatomal level of T10 was significantly longer in groups AF10, 69 min (56) and AF20, 69 min (45) than in group AF0, 41 min (35) (p = 0.013). Motor block duration was similar in all groups (median 120 min). Group AF20 patients experienced pruritus significantly more often than patients in the other groups (p = 0.039). No acute or late anesthetic side effects occurred, and satisfaction with the anesthetic technique was the same in all groups (97% satisfied). Conclusions Fentanyl 10 or 20 A mu g as additive to articaine for spinal anesthesia prolonged the duration of sensory block significantly and similarly. Fentanyl 20 A mu g was more often associated with pruritus than fentanyl 10 A mu g.Peer reviewe

Spinalna anestezija u dnevnoj kirurgiji - rana iskustva

Day surgery is a term that refers to performing an operation under anesthesia without needing to stay in the hospital for more than 24 hours. Day surgery has many advantages over surgery that involves a multiple-day hospital stay. Anesthesia for day surgery must have a rapid onset of action, a rapid cessation of action, and be free of, or have minimal side effects. For many years, general anesthesia was believed to be the anesthesia of choice for day surgery due to the delayed onset of local anesthetic after spinal anesthesia, a much longer duration of motor function recovery after surgery with spinal anesthesia compared to general anesthesia, and a more frequent incidence of side effects with spinal anesthesia, such as urinary retention or post-puncture headache. However, with the discovery of new, shorter-acting local anesthetics, and the use of smaller-diameter spinal needles, spinal anesthesia is becoming an equivalent anesthetic option for day surgery, if not a better one. Our early expiriences with spinal anesthesia in day surgery are excellent.Dnevna kirurgija podrazumijeva izvođenje operacije uz boravak u bolnici kraći od 24 sata. Dnevna kirurgija ima mnoge prednosti pred kirurgijom koja podrazumijeva boravak u bolnici kroz nekoliko dana. Anestezija za dnevnu kirurgiju mora imati brzi početak djelovanja, brzi prekid učinka i biti bez ili imati minimalne nuspojave. Dugi niz godina se vjerovalo da je anestezija izbora za dnevnu kirurgiju opća anestezija zbog odgođenog početka djelovanja lokalnih anestetika koji se upotrebljavaju za spinalnu anesteziju, odgođenog oporavka motorike nakon spinalne anestezije u usporedbi sa općom anestezijom i veće učestalosti nekih nuspojava nakon spinalne anestezije, poput retencije mokraće ili postpunkcijske glavobolje. Međutim, s otkrićem novih kratkodjelujućih lokalnih anestetika, te primjene spinalnih igala manjeg promjera, spinalna anestezija je postala jednakovrijedna općoj anesteziji, ako ne i bolji izbor. Naša rana iskustva sa spinalnom anestezijom u dnevnoj kirurgiji su izvrsna

Local Anaesthetics for Spinal Anaesthesia in Day-Case Surgery

Day-case procedures require a high turnover, high quality and low costs. Lidocaine has long been the gold standard for ambulatory spinal anaesthesia. However, the risk of transient neurological symptoms (TNS) limits its use. The perfect local anaesthetic for spinal anaesthesia in day-case surgery should have fast recovery, fast voiding time and a low risk on TNS and urinary retention. Urinary retention is a result of prolonged sensory blockade of the pelvic nerves and is local anaesthetic dose and potency dependent. As a substitute for lidocaine, several local anaesthetics have been suggested in various doses or combinations with or without additives. However, not all are registered for spinal use or have a short-acting profile. The use of additives has been subject of debate because of possible delay in the recovery of bladder. Recently, the old local anaesthetics chloroprocaine and prilocaine were reintroduced in the market. They provide rapid recovery after spinal anaesthesia in day-case surgery. This chapter gives an overview of the local anaesthetics suitable for spinal anaesthesia in day-case surgery, the advantages and disadvantages and the influence on discharge time and recovery of bladder function

Day-case anaesthesia in adult knee arthroscopy : With special reference to recovery and cost-effectiveness after general and spinal anaesthesia

AbstractThe number of ambulatory surgical procedures is increasing throughout the world. This is partly due to the development of a number of new anaesthetic, analgesic and adjuvant drugs, each with more rapid onset and shorter duration of action, over the past two decades. An interest in the issues discussed in this thesis arose out a desire to improve the quality of anaesthesia for patients who undergo day-case surgery. A second aim was to compare the different anaesthetic methods in terms of recovery from anaesthesia and costs.A total of 233 patients undergoing day-case knee arthroscopy under either 2% or 5% lidocaine spinal anaesthesia or general anaesthesia with desflurane, isoflurane, propofol or sevoflurane were investigated in two prospective, randomised clinical trials. The overall aims were to find the most suitable, satisfactory and economically feasible method for adult ambulatory knee arthroscopy and to assess the factors that affect the immediate postoperative period and the one-week recovery profile at home.The patients were highly satisfied with all the methods of anaesthesia. There was a slight tendency in favour of general anaesthesia compared to spinal anaesthesia. The general level of pain after ambulatory knee surgery was low after the first few hours postoperatively and continued to be low during the first postoperative week. After short-acting general anaesthesia with desflurane, isoflurane and propofol, home readiness was achieved over two hours earlier than after 5% lidocaine spinal anaesthesia. Home readiness was significantly delayed after 2% lidocaine spinal anaesthesia compared to sevoflurane inhalation anaesthesia. General anaesthesia with isoflurane was cheaper than the other general anaesthetics, i.e. desflurane, sevoflurane, propofol, or 2% and 5% lidocaine spinal anaesthesias. Propofol anaesthesia was the most expensive. The spinal anaesthesia patients had a higher incidence of headache, backache and lower leg pain during the first postoperative week than the patients who had had general anaesthesia.In busy ambulatory surgery units, remarkable savings may be achieved by using short-acting general anaesthetics, i.e. desflurane and isoflurane, instead of propofol or sevoflurane general anaesthesias or lidocaine spinal anaesthesia. This is due to the lower costs of desflurane and isoflurane compared to sevoflurane and propofol and the shorter time needed for postoperative care compared to spinal anaesthesia. Academic Dissertation to be presented with the assent of the Faculty of Medicine, University of Oulu, for public discussion in the Auditorium 1 of the University Hospital of Oulu, on September 13th, 2002, at 12 noon.Abstract The number of ambulatory surgical procedures is increasing throughout the world. This is partly due to the development of a number of new anaesthetic, analgesic and adjuvant drugs, each with more rapid onset and shorter duration of action, over the past two decades. An interest in the issues discussed in this thesis arose out a desire to improve the quality of anaesthesia for patients who undergo day-case surgery. A second aim was to compare the different anaesthetic methods in terms of recovery from anaesthesia and costs. A total of 233 patients undergoing day-case knee arthroscopy under either 2% or 5% lidocaine spinal anaesthesia or general anaesthesia with desflurane, isoflurane, propofol or sevoflurane were investigated in two prospective, randomised clinical trials. The overall aims were to find the most suitable, satisfactory and economically feasible method for adult ambulatory knee arthroscopy and to assess the factors that affect the immediate postoperative period and the one-week recovery profile at home. The patients were highly satisfied with all the methods of anaesthesia. There was a slight tendency in favour of general anaesthesia compared to spinal anaesthesia. The general level of pain after ambulatory knee surgery was low after the first few hours postoperatively and continued to be low during the first postoperative week. After short-acting general anaesthesia with desflurane, isoflurane and propofol, home readiness was achieved over two hours earlier than after 5% lidocaine spinal anaesthesia. Home readiness was significantly delayed after 2% lidocaine spinal anaesthesia compared to sevoflurane inhalation anaesthesia. General anaesthesia with isoflurane was cheaper than the other general anaesthetics, i.e. desflurane, sevoflurane, propofol, or 2% and 5% lidocaine spinal anaesthesias. Propofol anaesthesia was the most expensive. The spinal anaesthesia patients had a higher incidence of headache, backache and lower leg pain during the first postoperative week than the patients who had had general anaesthesia. In busy ambulatory surgery units, remarkable savings may be achieved by using short-acting general anaesthetics, i.e. desflurane and isoflurane, instead of propofol or sevoflurane general anaesthesias or lidocaine spinal anaesthesia. This is due to the lower costs of desflurane and isoflurane compared to sevoflurane and propofol and the shorter time needed for postoperative care compared to spinal anaesthesia

Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report

Introduction: Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery. Case presentation: We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively. Conclusion: A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge. © 2009 Roidis et al; licensee Cases Network Ltd