A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache.

PURPOSE OF REVIEW: The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. RECENT FINDINGS: PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1 week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.

Metabolic and the Surgical Stress Response Considerations to Improve Postoperative Recovery.

PURPOSE OF REVIEW: Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes. RECENT FINDINGS: A PubMed literature search was performed for articles that included the terms of metabolic surgical stress response considerations to improve postoperative recovery. The surgical stress response occurs due to direct and indirect injuries during surgery. Direct surgical injury can result from the dissection, retraction, resection, and/or manipulation of tissues, while indirect injury is secondary to events including hypotension, blood loss, and microvascular changes. Greater degrees of tissue injury will lead to higher levels of inflammatory mediator and cytokine release, which ultimately drives immunologic, metabolic, and hormonal processes in the body resulting in the stress response. These processes lead to altered glucose metabolism, protein catabolism, and hormonal dysregulation among other things, all which can impede recovery and increase morbidity. Fluid therapy has a direct effect on intravascular volume and cardiac output with a resultant effect on oxygen and nutrient delivery, so a balance must be maintained without excessively loading the patient with water and salt. All in all, attenuation of the surgical stress response and maintaining organ and thus whole-body homeostasis through enhanced recovery protocols can speed recovery and reduce complications. The present investigation summarizes the clinical application of enhanced recovery pathways, and we will highlight the key elements that characterize the metabolic surgical stress response and improved postoperative recovery.

Newer nerve blocks in pediatric surgery.

PURPOSE OF THE REVIEW: The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques and traditional nerve blocks. RECENT FINDINGS: The number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated lack of major complications and general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound-guided regional anesthesia has not only improved the safety profile, but also increased the efficacy of both peripheral nerve blocks and perineural catheters. SUMMARY: As the push for multimodal analgesia increases and the breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.

Rhabdomyolysis: pathogenesis, diagnosis, and treatment.

BACKGROUND: Rhabdomyolysis is a complex medical condition involving the rapid dissolution of damaged or injured skeletal muscle. METHODS: This review focuses on the epidemiology, pathophysiology, causes, presentation, diagnosis, complications, management, and anesthetic considerations related to rhabdomyolysis. RESULTS: Any form of muscle damage--and by extension any entity that causes muscle damage--can initiate rhabdomyolysis. One of the most important treatment goals when rhabdomyolysis is suspected is avoiding acute kidney injury. CONCLUSION: All clinicians should be aware of common causes, diagnosis, and treatment options.