Standard procedures in nonoperating room anesthesia.

PURPOSE OF REVIEW: This article provides an overview of standard procedures currently performed in nonoperating room anesthesia (NORA) and highlights anesthetic implications. RECENT FINDINGS: Novel noninvasive interventional procedures remain on the rise, accelerating demand for anesthesia support outside the conventional operating room. The field of interventional oncology has introduced a variety of effective minimally invasive therapies making interventional radiology gain a major role in the management of cancer. Technical innovation brings newer ablative and embolotherapy techniques into practice. Flexible bronchoscopy has replaced rigid bronchoscopy for many diagnostic and therapeutic indications. Endobronchial ultrasonography now allows sampling of mediastinal, paratracheal, or subcarinal lymph nodes rendering more invasive procedures such as mediastinoscopy unnecessary. Similarly, endoscopic ultrasonosgraphy currently plays a central position in the management of gastrointestinal disease. Sophisticated catheter techniques for ablating cardiac arrhythmias have become state of the art; Watchman procedure gaining position in the prevention of stroke resulting from atrial fibrillation. SUMMARY: NORA is a rapidly evolving field in anesthesia. Employing new technology to treat a wide variety of diseases brings new challenges to the anesthesiologist. Better understanding of emerging interventional techniques is key to safe practice and allows the anesthesia expert to be at the forefront of this swiftly expanding multidisciplinary arena.

Regional anesthesia and perioperative outcome: what is new?

PURPOSE OF REVIEW: This review of the most recent publications is aimed to look at the current developments regarding the effects of regional anesthesia on perioperative outcome. RECENT FINDINGS: The debate continues on whether regional anesthesia and analgesia improve outcome or not. Researchers are still divided in their views. While previous meta-analyses are more favorable, more recent trials are rather on the con side. In an attempt to lessen heterogeneity, meta-analyses have now incorporated data from more recent trials to perform subgroup analyses. Such analyses persistently show the same positive results. The established outcome effects of regional anesthesia are mostly due its ability to provide superior analgesia, its ability to reduce the perioperative stress response and subsequent physiologic perturbations, and its ability to reduce pulmonary complications. Its potential to prevent cardiac morbidity in patients undergoing coronary artery bypass grafting is investigated further by looking at valuable specific biological markers like troponin I and natriuretic peptides. Intrathecal opioids do not seem to improve outcome, unlike the intrathecal local anesthetics. The latter improve outcome presumably by blocking the surgical stress response. In contrast, opioids, non-steroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors have been shown not to impact outcome presumably by not being able to interfere with the stress response. The safety and efficacy of epidural or spinal anesthesia for spinal surgery continue to be demonstrated by current studies. SUMMARY: Despite the controversies, the numerous potential benefits and advantages of regional anesthesia are keys to its continued popularity. With constant search for new scientific clues by improving experimental designs, valuable evidence slowly unfolds. Regional anesthesia certainly takes a leading role in the current trends for a multimodal approach of perioperative pain management.