Recent technological advancements in regional anesthesia.

Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.

Pharmacologic Considerations of Anesthetic Agents in Pediatric Patients: A Comprehensive Review.

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.

Multimodal Analgesia, Current Concepts, and Acute Pain Considerations.

PURPOSE OF REVIEW: Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine. RECENT FINDINGS: Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.

Pain in the Elderly.

Pain management in the elderly has increasingly become problematic in the USA as the aged population grows. The proportion of the population over 65 continues to climb and may eclipse 20 % in the next decade. In order to effectively diagnosis and treat these patients, a proper history and physical exam remain essential; pain assessment scales such as the Verbal Descriptor Scales (VDS), the Numerical Rating Scales (NRS), and the Visual Analogue Scales (VAS) often but not always prove beneficial. The conditions most frequently afflicting this population include osteoarthritis, diabetic neuropathy, post-herpetic neuralgia, and lower back pain which include spondylosis and radiculopathies. While the normal aging process does not necessarily guarantee symptoms of chronic pain, elderly individuals are far more likely to develop these painful conditions than their younger counterparts. There are many effective treatment modalities available as potential therapeutic interventions for elderly patients, including but not limited to analgesics such as NSAIDs and opioids, as well as multiple interventional pain techniques. This review will discuss chronic pain in the elderly population, including epidemiology, diagnostic tools, the multitude of co-morbidities, and common treatment modalities currently available to physicians.

Left-to-right cardiac shunt: perioperative anesthetic considerations.

Congenital heart disease (CHD) affects roughly 8/1000 live births. Improvements in medical and surgical management in recent decades have resulted in significantly more children with left-to-right cardiac shunts surviving into adulthood. Surgical care of these patients for their original cardiac defect(s) or other non-cardiac medical conditions requires thorough understanding of cardiopulmonary changes and mastery of treatment options. Commonly encountered CHD with left-to-right shunt include atrial septal defect (ASD), ventricular septal defect (VSD), endocardial cushion defect (ECD) and patent ductus arteriosus (PDA). The key pathological change is increased pulmonary vascular resistance (PVR) and pressure secondary to increased blood flow from the left-to-right shunt. Increasing PVR and pulmonary arterial hypertension (PAH) will lead to reversed direction of blood flow through the cardiac defect (Eisenmenger Syndrome) and heart failure. Cardiac defects with left-to-right shunt generally require surgical or trans-catheter repair at an early age. We review the current concepts and general principles of perioperative anesthetic management of CHD, including neuraxial anesthesia. Current techniques and unique pharmacodynamic and pharmacokinetic effects of some commonly used anesthetic agents in patients with left-to-right shunt are also reviewed.