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1.  Perioperative Management of Interscalene Block in Patients with Lung Disease 
Case Reports in Anesthesiology  2013;2013:986386.
Interscalene nerve block impairs ipsilateral lung function and is relatively contraindicated for patients with lung impairment. We present a case of an 89-year-old female smoker with prior left lung lower lobectomy and mild to moderate lung disease who presented for right shoulder arthroplasty and insisted on regional anesthesia. The patient received a multimodal perioperative regimen that consisted of a continuous interscalene block, acetaminophen, ketorolac, and opioids. Surgery proceeded uneventfully and postoperative analgesia was excellent. Pulmonary physiology and management of these patients will be discussed. A risk/benefit discussion should occur with patients having impaired lung function before performance of interscalene blocks. In this particular patient with mild to moderate disease, analgesia was well managed through a multimodal approach including a continuous interscalene block, and close monitoring of respiratory status took place throughout the perioperative period, leading to a successful outcome.
doi:10.1155/2013/986386
PMCID: PMC3863477  PMID: 24369510
2.  Lessons Learned with Extended-release Epidural Morphine after Total Hip Arthroplasty 
An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone.
Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1181-3
PMCID: PMC2835616  PMID: 20012719
3.  Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus 
All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.
doi:10.4061/2011/976904
PMCID: PMC3168940  PMID: 21991449
4.  Alvimopan for the Management of Postoperative Ileus After Bowel Resection: Characterization of Clinical Benefit by Pooled Responder Analysis 
World Journal of Surgery  2010;34(9):2185-2190.
Background
A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.
Methods
Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3–8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.
Results
Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.
Conclusions
On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.
doi:10.1007/s00268-010-0635-9
PMCID: PMC2917559  PMID: 20526599

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