Anesthesia & Analgesia Vol 109 Issue 01 2009


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The effectiveness of some analgesic interventions discussed in this section is listed in Table 3. We identified 1 study examining acetaminophen administration postoperatively in patients undergoing THA. Acetaminophen should be administered on a scheduled basis. If the patient is not yet tolerating oral intake, scheduled IV acetaminophen, if available, can be administered.

Provided no contraindication, acetaminophen should be administered on a scheduled basis. If the patient is not yet tolerating oral intake, then scheduled IV NSAIDs can be provided and subsequently converted to an oral formulation when appropriate. Typical doses and choices of NSAIDs for an average-sized adult without contraindications include ketorolac 15—30 mg IV every 6 hours and ibuprofen — mg orally per OS every 6 hours when the patient is tolerating oral intake.

Review ARTICLE

Assuming no contraindications, administration of a COX-2 inhibitor in place of ibuprofen would also be appropriate. Dextromethorphan is commonly used as an antitussive agent and an antagonist at the N -methyl- d -aspartate receptor. There are no studies examining dextromethorphan specifically in patients undergoing THA. The earlier SR 98 failed to quantitatively combine the data into a pooled estimate. The optimal dose, timing, and duration of dextromethorphan are uncertain. Dextromethorphan may be associated with nausea, vomiting, dizziness, lightheadedness, and sedation.

There is limited evidence to guide the routine use of dextromethorphan for analgesia after THA.

As part of an overall strategy of opioid-sparing analgesia, dextromethorphan may be useful, but it should only be considered on an individual basis. Gabapentinoids are analgesic and opioid-sparing; however, the analgesic efficacy of gabapentinoids after THA is uncertain, especially when multiple nonopioid analgesics are administered together.

Local anesthetics may be administered via continuous wound infusions to provide nonopioid analgesia at the incision site. There are no studies investigating continuous wound infusions of local anesthetics for patients undergoing THA. There is insufficient evidence to support the routine use of continuous wound infusions for post-THA analgesia.

Sensory afferents from the hip joint arise from several branches of the lumbar plexus. The risk of falls caused by a lumbar plexus block is also uncertain but should be considered in high-risk patients. Where local resources and expertise permit, and provided no patient contraindication, the use of a lumbar plexus block can be considered as part of a multimodal approach to post-THA analgesia. Patients should be monitored for motor block and risk of falls. The analgesic efficacy of tramadol monotherapy for patients undergoing THA surgery is not supported.

However, as part of a multimodal regimen, tramadol may be considered, provided there is no contraindication. Traditionally, opioids form the basis for postoperative analgesia.

CLINICAL APPLICATIONS OF CSE

ERAS pathways attempt to limit opioid use, limiting opioid-related side effects that can delay patient recovery. One caveat for opioid use in ERAS pathways relates to opioid-tolerant patients. These patients will require continuation of their baseline opioid requirements to prevent withdrawal.

Abstracts - - Anaesthesia - Wiley Online Library

The demand for THA is escalating worldwide. These needs have led to the adoption of ERAS in multiple surgical subspecialties as a framework for providing evidence-based best practice and improving patient outcomes. The evidence review provides several recommendations for pre-THA care. The optimal CHO-containing solution simple [eg, glucose] versus complex [eg, maltodextrin] is unclear. The preoperative fasting duration can likewise be safely limited to 6 hours for solid food intake and 2 hours for clear beverages.

Optimal perioperative analgesia and PONV prophylaxis start preoperatively, with evidence supporting an orally administered bundle, including acetaminophen and an NSAID. The primary goals of intraoperative ERAS care for THA focus on a standardized anesthetic regimen and transition to effective postoperative analgesia, enabling early enteral intake and effective mobilization.


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There is a range of recommended techniques, and we recognize that some practice settings may be limited in the resources and expertise required to provide some of these techniques. Where possible, the evidence suggests, and we recommend, a primary neuraxial anesthetic for THA. Where patient contraindication or practice settings limit the use of neuraxial anesthesia, a general anesthetic that includes a protective lung ventilation strategy should be provided. It is also appropriate to consider postoperative analgesia during the intraoperative phase of care. We recommend the use of opioid-sparing regional analgesic techniques wherever patient conditions and local resources permit.

We recommend that TXA should be given to all patients, assuming no contraindication.

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PONV prophylaxis should be provided based on patient risk factors. The evidence basis to guide the optimal IV fluid regimen and associated volume-status monitoring in THA are limited; however, the available literature supports the judicious use of fluids to achieve euvolemia. That being said, patients with significant comorbidities or significant blood loss may benefit from more intense hemodynamic monitoring. Effective, multimodal analgesia forms the cornerstone of post-THA care. Opioid monotherapy should be avoided. Multimodal analgesia may be achieved by a combination of analgesic modalities, including regional analgesia.

Continuation of multimodal IV agents is recommended until the patient is tolerating an oral diet. It must be noted that recent publications have questioned the analgesic benefits of gabapentinoids. A few points should be noted about the use of regional anesthesia in THA. The data on the benefits of regional anesthesia are generally not in the context of an ERAS pathway, so the actual benefits of regional anesthesia in the presence of a multimodal analgesia regimen and ERAS pathway are not clear.

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Based on the literature found, we also felt obligated to list the evidence for IT opioid alone no local anesthetic and lumbar plexus block although realistically; these techniques are probably much less commonly used clinically than neuraxial local anesthetic—based epidural and spinal anesthesia. Although ERAS is an effective strategy and has been shown to significantly reduce the length of stay and incidence of complications, 10 protocol implementation requires collaboration between disciplines, together with support from hospital administrators and policymakers.

The evidence provided regarding many of the enhanced recovery pathways elements is in flux and new evidence continues to be published. The recommendations provided on this document have been based on the best evidence available at the time of our literature searches—the development of recommendations is a dynamic process such that protocols should be modified when new evidence is made available. Ultimately, we hope these initiatives will allow hospitals to not only meet the increasing demand for THA but also to improve quality of recovery and patient safety while hopefully decreasing costs of medical care.

Name: Ellen M. Soffin, MD, PhD. Contribution : This author helped with the conception and design, analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. Conflicts of Interest: None. Name: Melinda M. Contribution: This author helped with the conception and design, analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. Conflicts of Interest: M. Name: Clifford Y. Conflicts of Interest: C. Name: Stephen L. Kates, MD. Contribution: This author helped with the analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content.

Name: Elizabeth C. Wick, MD. Conflicts of Interest: E. Name: Michael J. Name: Christopher L.

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Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009
Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009
Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009
Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009
Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009
Anesthesia & Analgesia Vol 109 Issue 01   2009 Anesthesia & Analgesia Vol 109 Issue 01 2009

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