https://faculty.washington.edu/alexbert/Shoulder/MedConsult/ACC-AHAPracticeGuilines.pdf

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

reatment of postoperative pain is provided for humanitarian reasons and to alleviate nocicepT tion-induced responses, such as the endocrine metabolic response to surgery, autonomic reflexes with adverse effects on organ function, reflexes leading to muscle spasm, and other undesirable results (1). During the last decade there has been a virtual explosion in our knowledge of basic pain physiology (2,3), but the implications for clinical practice have been less substantial. The explanation for the discrepancy between the fast progress in basic pain pathophysiology and the rather slow advances in providing optimal postoperative pain treatment may be several, but one important factor may be that more than 95% of the literature on postoperative pain treatment has considered unimodal treatment. We have emphasized previously that total or optimal pain relief allowing normal function can not be achieved by a single drug or method without major strain on equipment and surveillance systems or without significant side effects (4). Therefore, we have recommended combined analgesic regimens (balanced analgesia) or a multimodal approach to the treatment of postoperative pain (4). The rationale for this strategy is achievement of sufficient analgesia due to additive or synergistic effects between different analgesics, with concomitant reduction of side effects, due to resulting lower doses of analgesics and differences in side-effect profiles. We summarize here the existing knowledge concerning the efficacy of analgesic combination therapy from postoperative pain studies. The effects on postoperative outcome are not included, because of lack of sufficient studies. We also exclude obstetric and pediatric pain, which may represent special pain entities and solutions for treatment, although they obviously share many of the problems of general postoperative pain. Primary emphasis will be placed on moderate and severe pain and the use of and need for

The value of "multimodal" or "balanced analgesia" in postoperative pain treatment.

Epidural anesthesia and analgesia. Their role in postoperative outcome.

Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.

Local Anesthetics and the Inflammatory Response: A New Therapeutic Indication? Markus Hollmann;Marcel Durieux; Anesthesiology

Local anesthetics and the inflammatory response: a new therapeutic indication?

Preoperative use of angiotensin-converting enzyme (ACE) inhibitors is common and has been associated with hypotension at separation from cardiopulmonary bypass (CPB). This study prospectively examined the influence of chronic preoperative ACE inhibitor use and other perioperative factors on the incidence of vasoconstrictor therapy required to maintain systolic blood pressure at more than 85 mm Hg despite a normal cardiac output after CPB in 4301 adults undergoing elective coronary artery and/or valve surgery. Hypothermic, nonpulsatile CPB and either opioid or ketamine-benzodiazepine anesthesia were common features of the operations. At least two vasoconstrictor infusions (phenylephrine, norepinephrine, or dopamine) were required for low perfusion pressure despite adequate cardiac output after CPB in 7.7% of 519 ACE-inhibited patients and 4.0% of 3782 patients not receiving ACE inhibitors (P = 0.0001). In the first 4 h after arrival in the intensive care unit, the need for vasoconstrictor infusions to treat hypotension with adequate cardiac output did not differ, although more ACE-inhibited patients (6.4%) exhibited low values of systemic vascular resistance ( or = 2 vasoconstrictor infusions after CPB. No other preoperative drug therapy significantly altered this outcome.

Angiotensin-converting Enzyme Inhibitors Increase Vasoconstrictor Requirements After Cardiopulmonary Bypass

Autologous blood donation: hemodynamics in a high-risk patient population.

Epidural anesthesia and analgesia decreases postoperative hypercoagulability in high-risk vascular patients

The effects of dodium nitroprusside (SNP) on total, ipsilateral cerebral blood flow (CBF) in the unanesthetized and anesthetized goat was evaluated under four conditions: 1) bolus injection of SNP into the cerebral circulation via the temporal artery; 2) continuous infusion of SNP into the temporal artery in amounts too small to affect the peripheral circulation (0.57-1.14 mug/kg/min); 3) intravenous infusion of SNP; 4) continuous intravenous infusion of SNP with a bolus injection af angiotensin. Small doses (20, 40, and 80 mug) of SNP injected directly in the cerebral circulation of the awake goat produced immediate increases of 21 +/- 8, 36 +/- 8, and 48+/- 10 per cent, respectively, in CBF lasting 1 to 3 min without causing peripheral cardiovascular changes. The effects of SNP were attenuated by 1.5 per cent halothane anesthesia. Continuous infusion of SNP into the temporal artery in amounts too small to cause peripheral cardiovascular effects produced sustained increases in CBF averaging 31+/- 8 percent; CBF returned to preinfusion values upon cessation of infusion. Intravenous infusion of SNP in both anesthetized and unanesthetized animals in recommended clinical dosages (3-8 mug/kg/min) produced hypotension but did not significantly alter CBF. However, upon injection of angiotensin (1.43 mug/kg), both peripheral blood pressure and CBF increased sharply, suggesting that SNP may impair autoregulation of CBF. The results of this study indicate that SNP dilates the cerebral vascular system in a way that is probably similar to its effects on other vascular beds.

A. D. Ivankovich

Papers

Angiotensin-converting Enzyme Inhibitors Increase Vasoconstrictor Requirements After Cardiopulmonary Bypass

Autologous blood donation: hemodynamics in a high-risk patient population.

Epidural anesthesia and analgesia decreases postoperative hypercoagulability in high-risk vascular patients

Sodium Nitroprusside and Cerebral Blood Flow in the Anesthetized and Unanesthetized Goat

Cardiac output during ritodrine treatment in premature labor.