Epidural technique for postoperative pain: gold standard no more?

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.     

A critical look at diagnostic criteria: time for a change?

There are certain thought barriers involved in making diagnostic-classification criteria in diseases of unknown origin. Among these are a lack of appreciation of the issue of circular logic, the basic oneness of diagnostic and classification criteria, the lack of appreciation as to why we make such criteria in the first place, and the lack of importance informing our patients that we do as well as should treat them without a frm diagnosis in many instances. The relevance of these thought barriers to the new American College of Rheumatology/European Union League Against Rheumatism (ACR/EULAR) Rheumatoid Arthritis (RA) classification criteria are also discussed.     

Acute kidney injury in critical care: time for a paradigm shift?

PURPOSE OF REVIEW: Acute alterations in renal function are commonly encountered in various settings with varied clinical manifestations ranging from a minimal elevation in serum creatinine to anuric renal failure. Our knowledge of human acute kidney injury has been fairly stagnant, until recently largely limited by a lack of concerted efforts in the field. This review summarizes the recent advances and provides an overview of emerging trends in this field. RECENT FINDINGS: One of the limitations in our knowledge of human acute kidney injury has been the lack of a standardized definition and staging criteria for this disorder. New information on the epidemiology and outcomes of acute kidney injury has emerged providing an opportunity to reappraise our approach to this disease. Also, there has been new work on the relationship of alterations of renal function to short and long-term outcomes, particularly mortality. SUMMARY: To translate advances from basic research to clinical application a multidisciplinary approach is required. New research in the field of biomarkers combined with clinical markers will lead to therapies that can be introduced earlier in the course of the disease and, hopefully, lead to a decrease in mortality from this potentially reversible condition.     

Is revascularization and limb salvage always the treatment for critical limb ischemia?

Despite marked advances in the technical ability to perform lower extremity revascularization, the decision whether to perform primary amputation or attempt revascularization in high risk patients is a major part of modern vascular care. With an aging population and improved medical care that has increased life expectancy, more patients with severe systemic disease are presenting with critical limb ischemia (CLI). In addition, it is well recognized that CLI patients suffer diagnostic delays and poor risk factor modification, which in part contributes to limb loss and poor patient survival. Unlike other disease entities, CLI does not have a clear clinical pattern that provides consistent entry to medical care and uniform treatment algorithm. In this commentary we will discuss the issue from several viewpoints. The unique features of the antecedent natural history of CLI will be presented. Available data on functional outcomes on both therapies for CLI will be presented. Morbidity and mortality of both approaches will be covered, including the risk of multiple procedures, followed by an examination of specific problematic patient populations. Finally, we will close with some potential approaches to these problems and future studies that are needed to push forward our ability to appropriately make these difficult decisions for an increasingly aging population.