Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2
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Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2
Regional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2pain relief with the least amount of medication. This is because equianalgesi-cally the doses of opioids delivered to the epidural and intrathecal spaces are several times more potent than rhe same medications given intravenously. Adding a local anesthetic such as bupivacaine or ropivacaine to rhe e Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2pidural solution creates a synergistic effect that enhances rhe overall analgesic effect of the epidural.For patient in critical care areas, the use oEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
f epidurals can provide excellent pain relief with less opioid than usually required. It can allow rhe patient with a thoracotomy or Hail chest to couRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2her regional technique in order to control pain that can last for several weeks at high intensity levels.In most cases rhe epidural is placed perioperarively and either used during surgery as an alternate to general anesthesia bur also as postoperative analgesia. The opioid medications used for epid Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2ural pain management bind to opioid receptors in rhe dorsal horn of the spinal cord and can produce effective analgesia at greatly reduced doses. TheEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
addition of local anesthetic allows the nerve roots closest to the placement site to be bathed in rhe epidural solution, causing localized pain reliefRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2resistant to epidural catheters fearing that they will have a needle in their backs during the entire time of infusion. Patients should be reassured that rhe needle is only used for placing rhe catheter and rhe tubing that remains is very small and soft.172 J3. Regional Techniques and Epidural Analg Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2esia for Pain ReliefPatients who are good candidates for epidural analgesia are patients with major surgeries or procedures such as:■Thoracotomy■LargeEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
abdominal surgeries■Aortic aneurysm repair■Orthopedic patients (total joint replacements)■Labor and delivery patients (used for delivery)■Trauma patiRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2 randomized to thoracic epidural and general anesthesia or general anesthesia only, length of stay was significantly reduced in the combined group and median intubation time and rhe incidence of arrhythmias were both significantly lower (Caputo er al., 2011). Additional findings indicated that altho Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2ugh there was an increased use of vasoconstrictors inrraoperatively in rhe combined anesthesia/anal-gesia group, impairment from pain was lower and moEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
rphine consumption was also lower in the combined group (Caputo et al., 2011).To place an epidural catheter, rhe patient is placed into a sirring or sRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2gh rhe skin of the back into rhe epidural space, which is really a potential space between the ligament flavum and the dura mater. Once fluid enters the epidural space it expands, much like blowing air into a flat paper bag expands rhe bag. Once rhe needle is placed at rhe correct dermatome, rhe epi Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2dural catheter is threaded through the needle and placement is confirmed by a technique called loss of resistance. This means that rhe resistance feltEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
by rhe tissue at the tip of the catheter is relieved once an open space such as the epidural space is reached. For epidural placement, the needle itsRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2esistance it is fairly certain that rhe catheter has entered rhe epidural space. After the catheter is determined to be placed properly, rhe practitioner can then bolus the catheter to determine the effect. The epidural space contains a variety of structures that include spinal nerve roots, far, are Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2olar tissue, lymph tissue, and blood vessels including a rich venous plexus (Rockford & Deruyter, 2009). Since the analgesic effect is so localized, tEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
he catheter is placed at rhe level of rhe expected surgical incision with catheter placement being done commonly in the thoracic and lumbar spinal levRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2 frnmEp idural Meducations 173 spread of the medication are the patient’s age and the volume of drug being infused (Rockford & De Ruyter, 2009).It is important to note that once the epidural catheter reaches the epidural space, it can migrate upward (rostral) or downward (caudal). This migration can Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2 affect rhe way rhe patient feels rhe analgesic effect. In some cases the epidural catheter provides analgesia to a nonoperative lower extremity whenEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
rhe intent is to provide analgesic to rhe operative extremity. This effect is caused by rhe curling of rhe catheter in rhe epidural space leading to aRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2gh rhe term spinal, when used, is closely associated with intrathecal placement. For some patients a single dose of preservative-free morphine is used as an adjunct to postoperative analgesia. These doses are commonly referred to as “single shots." They are given one rime only and an extended-releas Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2e morphine such as Astromorph, Duramorph, or DepoDur is used to extend rhe action of rhe medication for 24 hours. Since morphine is a hydrophilic mediEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
cation, it can spread throughout the CSF and extend the action of the medication. A single shot Duramorph injection is done using 0.1 to 0.3 mg with rRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2nfusion, rhe catheter extends directly into rhe thecal space and rhe medication flows into the CSF. Either opioids or local anesthetics can be used intrathecally, but continuous infusion of local anesthetics is associated in some cases with the development of cauda equina syndrome (Scientific Eviden Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2ce, 2005).Since medications inserted into the epidural space need to cross the dura, onset of action of epidural analgesia is slower when compared toEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
intrathecal administration. A hydrophilic medication such as a morphine is more useful as medications infused into rhe intrathecal space spread througRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2used epidurally may produce effective analgesia.EPIDURAL MEDICATIONSAll medications used for epidural analgesia should be preservative free since many preservatives such as alcohol can damage neural tissue. The opioid mpflirarinns ncprl fnr pnidiirnl nníilơpciíi íirp kocirallv rkp CÍ11TÌP rhnep n«;p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2rl174 73. Regional Techniques and Epidural Analgesia for Pain Reliefin combined solutions. When epidural is compared to intrathecal medication adminisEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
tration, rhe epidural route has fewer side effects and a lessened potential for respiratory depression (Rockford & DeRuyter, 2009).OpioidsMorphine, hyRegional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2ne and fentanyl with hydromophone having less evidence for use (American Society of Anesthesiologists [ASA], 2004).The choice of which medication to use for infusion is provider dependent and patient specific. If rhe patient has allergies to morphine, another medication is selected and adequate pain Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2 relief is rhe measure of effectiveness.When comparing the use of morphine versus fentanyl, the pharmacokinetics shows a differentiation of action. MoEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
rphine is a hydrophilic medication. When morphine is used in epidural solutions there is a rapid rise in morphine serum concentration, and the action Regional Techniques and Epidural Analgesia for Pain Relief in Critical CareEPIDURAL BASICSEpidural pain management can provide the largest amount of p Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2ration of rhe medication rises more slowly due to medication uptake by epidural fat and other epidural tissues. To approximate rhe action of IV medication administration, it takes about 25 hours for the lipid uptake of fentanyl to allow the drug to freely enter rhe circulatory system (Rockford & DeR Ebook Compact clinical guide to critical care, trauma, and emergency: Part 2uyter, 2009). Morphine has a naturally occurring longer action, while fentanyl has a shorter period of activity making it more suitable for use as anEbook Compact clinical guide to critical care, trauma, and emergency: Part 2
epidural PCA that is called patient controlled epidural analgesia (PCEA). Hydromorphone is a midrange medication whose action falls somewhere betweenGọi ngay
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