Regional Anesthesia in Patients on Anticoagulation Therapies-Evidence-Based Recommendations.

PURPOSE OF REVIEW: Anticoagulant use among patients is prevalent and increasing. It is important for anesthesiologists to be aware of patients on anticoagulants while performing regional anesthesia. RECENT FINDINGS: In recent years, the FDA has approved many new anticoagulants. With new drugs coming to the market, new side effect profiles should be considered when treating patients, especially when using regional anesthesia. Both ASRA and European agencies have laid out recommendations regarding anticoagulant use and neuraxial/regional techniques. Regarding newer anticoagulants, the guidelines for discontinuation prior to neuraxial injection are based on pharmacokinetics, including half-life duration for each drug. While each clinical scenario requires an individualized approach, general guidelines can serve as a starting point to help with anesthetic planning and potentially improve patient safety in this evolving field.

Emerging Novel Pharmacological Non-opioid Therapies in Headache Management: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic headache is a significant worldwide problem despite advances in treatment options. Chronic headaches can have significant a detrimental impact on the activities of daily living. RECENT FINDINGS: Patients who do not obtain relief from chronic head and neck pain from conservative treatments are commonly being managed with interventional treatments. These interventional treatment options include botulinum toxin A, injections, local occipital nerve anesthetic and corticosteroid infiltration, occipital nerve subcutaneous stimulation and occipital nerve pulsed radiofrequency (PRF), sphenopalatine ganglion block, and radiofrequency techniques. Recently, evidence has emerged to support non-opioid-based drug and interventional approaches. Overall, more research is necessary to clarify the safety and efficacy of interventional treatments and to better understand the pathogenesis of chronic headache pain.

Enhanced recovery pathways in orthopedic surgery.

The enhanced recovery after surgery (ERAS) concept, sometimes referred to as "fast track", "accelerated," or "Rapid Recovery" surgery, was first introduced in 1997. The concept of ERAS targets factors that delay postoperative recovery such as surgical stress and organ dysfunction. ERAS protocols or programs are a care package of evidence-based interventions used in a multimodal and coordinated clinical care pathway. They represent a multidisciplinary approach directed to reducing postoperative complications, shortening length of hospital stay, improving patient satisfaction, and accelerating recovery. ERAS was initially centered on abdominal and colorectal surgery patients; however, ERAS protocols have been widely extended to include other specialties. Orthopedic surgery, particularly elective hip and knee arthroplasty is one of such areas where ERAS principles have been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional recovery. The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care. A PubMed literature search was performed for articles that included the terms enhanced recovery and orthopedic surgery. In this article, we summarized the clinical application of ERAS and highlighted the key elements that characterize an enhanced recovery program.

New anticoagulants, reversal agents, and clinical considerations for perioperative practice.

There are several new anticoagulants on the market that will impact perioperative care, including the use of these anticoagulant drugs in the setting of regional anesthesia. The ideal pharmacological agent would prevent pathological thrombosis and allow for a normal response to vascular injury to limit bleeding. At present, all antithrombotic agents have increased bleeding risk as their main side effect. We describe the different categories of drugs, e.g., antiplatelet, anticoagulant, and thrombolytic, with particular emphasis on the new drugs that have been introduced into the market. These agents can be evaluated by a number of methods including low-, medium-, or high-risk procedures and guidelines and best practice standards that have been published regarding the amount of time to wait after stopping the medication and before performing a procedure, e.g., the American Society of Regional Anesthesia and Pain Medicine recommendations. The present investigation will also describe new reversal agents for anticoagulants and the implications of all these drugs for regional anesthesia.

Pulmonary vasodilators: Latest evidence and outcomes in the perioperative setting.

Numerous conditions give rise to pulmonary arterial hypertension (PAH), with most of them being idiopathic. Signs and symptoms are generally difficult to recognize initially because they present as nonspecific and typically are mistaken for age-related physiological processes or alternate medical conditions. Many advances have been made toward PAH-specific therapies that have led to advanced clinical management of the disease. The present investigation describes new pulmonary vasodilator agents that are currently available or under development that could impact perioperative management. The 6-min walk test is the gold standard in assessing the efficacy of any pulmonary hypertension treatment, and the only drug to show any mortality benefit in pulmonary hypertension is epoprostenol. The present investigation also describes the latest evidence on using these medications in the perioperative period, including clinical trials and practice guidelines. Future direction for research and clinical management of pulmonary hypertension is described.

Pharmacogenomics, precision medicine, and implications for anesthesia care.

The study of how individual genetic differences, known as polymorphisms, change the pharmacokinetics and pharmacodynamics of drugs is called pharmacogenomics. As the field of pharmacogenetics grows and continues to identify genetic polymorphisms, it is promising that the unmet need in this patient population may soon be addressed with personalized drug therapy based on the patient's genetic composition. Although encouraging, pharmacogenomic testing is underutilized in the United States and is often not covered by insurance companies. This manuscript describes the current state of precision medicine as it relates to perioperative care and how preoperative genomic analysis can help improve patient outcomes. This investigation also outlines future directions in this important and evolving field.