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Showing papers in "BJA: British Journal of Anaesthesia in 2005"


Journal ArticleDOI
TL;DR: The reader is introduced to the theory and practice of ultrasound-guided anaesthetic techniques in adults and children and considers their enormous potential to have a role in the future training of anaesthetists.
Abstract: The technology and clinical understanding of anatomical sonography has evolved greatly over the past decade. In the Department of Anaesthesia and Intensive Care Medicine at the Medical University of Vienna, ultrasonography has become a routine technique for regional anaesthetic nerve block. Recent studies have shown that direct visualization of the distribution of local anaesthetics with high-frequency probes can improve the quality and avoid the complications of upper/lower extremity nerve blocks and neuroaxial techniques. Ultrasound guidance enables the anaesthetist to secure an accurate needle position and to monitor the distribution of the local anaesthetic in real time. The advantages over conventional guidance techniques, such as nerve stimulation and loss-of-resistance procedures, are significant. This review introduces the reader to the theory and practice of ultrasound-guided anaesthetic techniques in adults and children. Considering their enormous potential, these techniques should have a role in the future training of anaesthetists.

618 citations


Journal ArticleDOI
TL;DR: Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay and patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.
Abstract: Background Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements. Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay. We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery. Methods This single centre, blinded, prospective controlled trial randomized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based (conventional) intraoperative fluid management. The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aiming for a CVP between 12 and 15 mm Hg. Results The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P Conclusions Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.

588 citations


Journal ArticleDOI
TL;DR: Predictive risk factors for chronic postoperative pain are: preoperative pain, repeat surgery, psychological vulnerability, workers compensation, a surgical approach with risk of nerve damage, moderate or severe intensity of acute postoperativePain, radiation therapy, neurotoxic chemotherapy, depression, neuroticism, and anxiety.
Abstract: That surgical injury can lead to chronic pain is now well established. 82 1 29 41 50 From these reviews and studies using a systematic collection of data, the estimated incidences of chronic pain after various procedures are: leg amputation about 60%, thoracotomy about 50%, breast surgery about 30%, cholecystectomy 10–20%, and inguinal herniorrhaphy about 10%. Predictive risk factors for chronic postoperative pain are: preoperative pain, repeat surgery, psychological vulnerability, workers compensation, a surgical approach with risk of nerve damage, moderate or severe intensity of acute postoperative pain, radiation therapy, neurotoxic chemotherapy, depression, neuroticism, and anxiety. 29 41 All these factors should be assessed in any study of

504 citations


Journal ArticleDOI
TL;DR: Acetaminophen combined with patient-controlled analgesia (PCA) with morphine induced a significant morphine-sparing effect but did not change the incidence of morphine-related adverse effects in the postoperative period.
Abstract: Background Acetaminophen is commonly used for the management of perioperative pain. However, there is a marked discrepancy between the extent to which acetaminophen is used and the available evidence for an analgesic effect after major surgery. The aim of this systematic review is to determine the morphine-sparing effect of acetaminophen combined with patient-controlled analgesia (PCA) with morphine and to evaluate its effects on opioid-related adverse effects. Methods MEDLINE and the Cochrane Library were searched to select randomized controlled trials which compared PCA morphine alone with PCA morphine plus acetaminophen administered orally or intravenously. Studies were evaluated for their quality based on the Oxford Quality Scale. Outcome measures were morphine consumption over the first 24 h after surgery, patient satisfaction and the incidence of morphine side-effects, including nausea and vomiting, sedation, urinary retention, pruritus and/or respiratory depression. Results Seven prospective randomized controlled trials, including 265 patients in the group with PCA morphine plus acetaminophen and 226 patients in the group with PCA morphine alone, were selected. Acetaminophen administration was not associated with a decrease in the incidence of morphine-related adverse effects or an increase in patient satisfaction. Adding acetaminophen to PCA was associated with a morphine-sparing effect of 20% (mean, −9 mg; CI −15 to −3 mg; P =0.003) over the first postoperative 24 h. Conclusion Acetaminophen combined with PCA morphine induced a significant morphine-sparing effect but did not change the incidence of morphine-related adverse effects in the postoperative period.

424 citations


Journal ArticleDOI
TL;DR: In most patients, the GlideScope provided a laryngoscopic view equal to or better than that of direct lARYngoscopy, but it took an additional 16 s (average) for tracheal intubation.
Abstract: Background. The GlideScope® Video Laryngoscope is a new intubating device. It was designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. The aim of the study was to describe the use of the GlideScope® in comparison with direct laryngoscopy for elective surgical patients requiring tracheal intubation. Methods. Two hundred patients were randomly assigned to intubation by direct laryngoscopy using a Macintosh size 3 blade (DL, n=100) or intubation using the GlideScope® (GS, n=100). Prior to intubation all patients were given a Cormack and Lehane (C&L) grade by a separate anaesthetist using a Macintosh size 3 blade. The patient was then intubated, using direct laryngoscopy or the GlideScope®, by a different anaesthetist during which the larynx was inspected and given a laryngoscopy score. Time to intubate was measured. Results. In the GS group, laryngoscopy grade was improved in the majority (28/41) of patients with C&L grade >1 and in all but one of patients who were grade 3 laryngoscopy (P Conclusion. In most patients, the GlideScope® provided a laryngoscopic view equal to or better than that of direct laryngoscopy, but it took an additional 16 s (average) for tracheal intubation. It has potential advantages over standard direct laryngoscopy for difficult intubations.

359 citations


Journal ArticleDOI
TL;DR: Knowledge of the properties of these drugs will help to ensure that problems can be avoided in most clinical situations, and treated appropriately (with 5-HT(2A) antagonists for severe cases) if they occur.
Abstract: Toxicity resulting from excessive intra-synaptic serotonin, historically referred to as serotonin syndrome, is now understood to be an intra-synaptic serotonin concentration-related phenomenon. Recent research more clearly delineates serotonin toxicity as a discreet toxidrome characterized by clonus, hyper-reflexia, hyperthermia and agitation. Serotonergic side-effects occur with serotonergic drugs, and overdoses of serotonin re-uptake inhibitors (SRIs) frequently produce marked serotonergic side-effects, and in 15% of cases, moderate serotonergic toxicity, but not to a severe degree, which produces hyperthermia and risk of death. It is only combinations of serotonergic drugs acting by different mechanisms that are capable of raising intra-synaptic serotonin to a level that is life threatening. The combination that most commonly does this is a monoamine oxidase inhibitor (MAOI) drug combined with any SRI. There are a number of lesser-known drugs that are MAOIs, such as linezolid and moclobemide; and some opioid analgesics have serotonergic activity. These properties when combined can precipitate life threatening serotonin toxicity. Possibly preventable deaths are still occurring. Knowledge of the properties of these drugs will therefore help to ensure that problems can be avoided in most clinical situations, and treated appropriately (with 5-HT2A antagonists for severe cases) if they occur. The phenylpiperidine series opioids, pethidine (meperidine), tramadol, methadone and dextromethorphan and propoxyphene, appear to be weak serotonin re-uptake inhibitors and have all been involved in serotonin toxicity reactions with MAOIs (including some fatalities). Morphine, codeine, oxycodone and buprenorphine are known not to be SRIs, and do not precipitate serotonin toxicity with MAOIs.

342 citations


Journal ArticleDOI
TL;DR: Ulasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics and the intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.
Abstract: in the ‘fascial click’ group (0.19 (SD 0.05) ml kg 1 vs 0.3 ml kg 1 , P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasoundguided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). Conclusions. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method. Br J Anaesth 2005; 95: 226–30

325 citations


Journal ArticleDOI
TL;DR: Strategies to prevent significant coagulopathy and to control critical bleeding effectively in the presence of coagULopathy may decrease the requirement for blood transfusion, thereby improving clinical outcome of patients with major trauma.
Abstract: Trauma is a serious global health problem, accounting for approximately one in 10 deaths worldwide. Uncontrollable bleeding accounts for 39% of trauma-related deaths and is the leading cause of potentially preventable death in patients with major trauma. While bleeding from vascular injury can usually be repaired surgically, coagulopathy-related bleeding is often more difficult to manage and may also mask the site of vascular injury. The causes of coagulopathy in patients with severe trauma are multifactorial, including consumption and dilution of platelets and coagulation factors, as well as dysfunction of platelets and the coagulation system. The interplay between hypothermia, acidosis and progressive coagulopathy, referred to as the 'lethal triad', often results in exsanguination. Current management of coagulopathy-related bleeding is based on blood component replacement therapy. However, there is a limit on the level of haemostasis that can be restored by replacement therapy. In addition, there is evidence that transfusion of red blood cells immediately after injury increases the incidence of post-injury infection and multiple organ failure. Strategies to prevent significant coagulopathy and to control critical bleeding effectively in the presence of coagulopathy may decrease the requirement for blood transfusion, thereby improving clinical outcome of patients with major trauma.

274 citations


Journal ArticleDOI
TL;DR: The physiology and pharmacology of the kidney; the characterization of tests of renal function; the cause of postoperative renal dysfunction; what is presently available for its prevention and treatment; and the effect of postoperatively renal impairment on patient outcome are considered.
Abstract: The development of perioperative acute renal failure is associated with a high incidence of morbidity and mortality. Although this incidence varies with different surgical procedures and with the definition used for renal failure, we now understand better the aetiology of the underlying problem. However, successful strategies to provide renal protection or strategies for 'rescue therapy' are either lacking, unsubstantiated by randomized clinical trials, or show no significant efficacy. The present review considers the physiology and pharmacology of the kidney; the characterization of tests of renal function; the cause of postoperative renal dysfunction; what is presently available for its prevention and treatment; and the effect of postoperative renal impairment on patient outcome.

268 citations


Journal ArticleDOI
TL;DR: The authors' data confirm a ceiling effect of buprenorphine but not fentanyl with respect to respiratory depression and the effect on PaCO2 was modest (maximum value measured, 5.5 kPa).
Abstract: Background There is evidence from animal studies suggesting the existence of a ceiling effect for buprenorphine-induced respiratory depression. To study whether an apparent ceiling effect exists for respiratory depression induced by buprenorphine, we compared the respiratory effects of buprenorphine and fentanyl in humans and rats. Methods In healthy volunteers, the opioids were infused i.v. over 90 s and measurements of minute ventilation at a fixed end-tidal P CO 2 of 7 kPa were obtained for 7 h. Buprenorphine doses were 0.7, 1.4, 4.3 and 8.6 μg kg−1 (n=20 subjects) and fentanyl doses 1.1, 2.1, 2.9, 4.3 and 7.1 μg kg−1 (n=21). Seven subjects received placebo. In rats, both opioids were infused i.v. over 20 min, and arterial P CO 2 was measured 5, 10, 15 and 20 min after the start of fentanyl infusion and 30, 150, 270 and 390 min after the start of buprenorphine infusion. Doses tested were buprenorphine 0, 100, 300, 1000 and 3000 μg kg−1 and fentanyl 0, 50, 68 and 90 μg kg−1. Results In humans, fentanyl produced a dose-dependent depression of minute ventilation with apnoea at doses ≥2.9 μg kg−1; buprenorphine caused depression of minute ventilation which levelled off at doses ≥3.0 μg kg−1 to about 50% of baseline. In rats, the relationship of arterial P CO 2 and fentanyl dose was linear, with maximum respiratory depression at 20 min (maximum P a CO 2 8.0 kPa). Irrespective of the time at which measurements were obtained, buprenorphine showed a non-linear effect on P a CO 2 , with a ceiling effect at doses >1.4 μg kg−1. The effect on P a CO 2 was modest (maximum value measured, 5.5 kPa). Conclusions Our data confirm a ceiling effect of buprenorphine but not fentanyl with respect to respiratory depression.

264 citations


Journal ArticleDOI
TL;DR: Functional haemodynamic parameters are superior to static indicators of cardiac preload in predicting the response to fluid administration and the RSVT and PPV were the most accurate predictors of fluid responsiveness.
Abstract: Background Prediction of the response of the left ventricular stroke volume to fluid administration remains an unsolved clinical problem. We compared the predictive performance of various haemodynamic parameters in the perioperative period in patients undergoing coronary artery bypass surgery. These parameters included static indicators of cardiac preload and functional parameters, derived from the arterial pressure waveform analysis. These included the systolic pressure variation (SPV) and its delta down component (dDown), pulse pressure variation (PPV), stroke volume variation (SVV), and a new parameter, termed the respiratory systolic variation test (RSVT), which is a measure of the slope of the lowest systolic pressure values during a standardized manoeuvre consisting of three successive incremental pressure-controlled breaths. Methods Eighteen patients were included into this prospective observational study. Seventy volume loading steps (VLS), each consisting of 250 ml of colloid administration were performed before surgery and after the closure of the chest. The response to each VLS was considered as a positive (increase in stroke volume more than 15%) or non-response. Receiver operating characteristic curves were plotted for each parameter to evaluate its predictive value. Results All functional parameters predicted fluid responsiveness better than the intrathoracic blood volume and the left ventricular end-diastolic area. Parameters with the best predictive ability were the RSVT and PPV. Conclusions Functional haemodynamic parameters are superior to static indicators of cardiac preload in predicting the response to fluid administration. The RSVT and PPV were the most accurate predictors of fluid responsiveness, although only the RSVT is independent of the settings of mechanical ventilation.

Journal ArticleDOI
TL;DR: Ketamine administered under sevoflurane anaesthesia causes a significant increase in BIS, RE and SE without modification of the RE-SE gradient, which is paradoxical in that it is associated with a deepening level of hypnosis.
Abstract: Background. The Bispectral Index (BIS) and spectral entropy of the electroencephalogram can be used to assess the depth of hypnosis. Ketamine is known to increase BIS in anaesthetized patients and may confound that index as a guide to steer administration of hypnotics. We compared the effects of ketamine on BIS, response entropy (RE) and state entropy (SE) during surgery under sevoflurane anaesthesia. Methods. Twenty-two women undergoing gynaecological surgery were enrolled in this double-blind, randomized study. Anaesthesia was induced i.v. and maintained with sevoflurane. Under stable surgical and anaesthetic conditions, patients were assigned to receive either a bolus of ketamine 0.5 mg kg−1 or the same volume of saline. Blood pressure, heart rate, BIS, RE and SE were measured every 2.5 min from 10 min before (baseline) until 15 min after ketamine or saline administration. The maximum relative increase in BIS, RE and SE compared with baseline was calculated for each patient. Values are mean ( sd ). Results. Baseline values were BIS 33 (4), RE 31 (5), SE 30 (5) for the ketamine patients and BIS 35 (3), RE 33 (5) and SE 32 (6) for the patients receiving saline. BIS, RE and SE increased significantly from 5 min (BIS) and 2.5 min (RE and SE) after ketamine administration, peaking at 46 (8) (BIS), 52 (12) (RE) and 50 (12) (SE) respectively. The maximum relative increase in RE [42.2 (10.4%)] and SE [41.6 (10.9)%] was higher than that of BIS [29.4 (10.4%)]. Blood pressure, heart rate and RE–SE gradient did not change in either group. Conclusions. Ketamine administered under sevoflurane anaesthesia causes a significant increase in BIS, RE and SE without modification of the RE–SE gradient. This increase is paradoxical in that it is associated with a deepening level of hypnosis.

Journal ArticleDOI
TL;DR: Dexmedetomidine provided adequate sedation in most of the children aged 1-7 yr without haemodynamic or respiratory effects during MRI procedures, and the quality of MRI was significantly better.
Abstract: Background We evaluated the sedative, haemodynamic and respiratory effects of dexmedetomidine and compared them with those of midazolam in children undergoing magnetic resonance imaging (MRI) procedures. Methods Eighty children aged between 1 and 7 yr were randomly allocated to receive sedation with either dexmedetomidine (group D, n=40) or midazolam (group M, n=40). The loading dose of the study drugs was administered for 10 min (dexmedetomidine 1 μg kg−1 or midazolam 0.2 mg kg−1) followed by continuous infusion (dexmedetomidine 0.5 μg kg−1 h−1 or midazolam 6 μg kg−1 min−1). Inadequate sedation was defined as difficulty in completing the procedure because of the child's movement during MRI. The children who were inadequately sedated were given a single dose of rescue midazolam and/or propofol intravenously. Mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation ( S p O 2 ) and ventilatory frequency (VF) were monitored and recorded during the study. Results The quality of MRI was significantly better and the rate of adequate sedation was higher in group D than in group M (P Conclusions Dexmedetomidine provided adequate sedation in most of the children aged 1–7 yr without haemodynamic or respiratory effects during MRI procedures.

Journal ArticleDOI
TL;DR: PCT and IL-6 appear to be early markers of subsequent postoperative sepsis in patients undergoing major surgery for cancer, which could allow identification of postoperativeSepsis complications.
Abstract: Background Patients who undergo major surgery for cancer are at high risk of postoperative sepsis. Early markers of septic complications would be useful for diagnosis and therapeutic management in patients with postoperative sepsis. The aim of this study was to investigate the association between early (first postoperative day) changes in interleukin 6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) serum concentrations and the occurrence of subsequent septic complications after major surgery. Methods Serial blood samples were collected from 50 consecutive patients for determination of IL-6, PCT and CRP serum levels. Blood samples were obtained on the morning of surgery and on the morning of the first postoperative day. Results Sixteen patients developed septic complications during the first five postoperative days (group 1), and 34 patients developed no septic complications (group 2). On day 1, PCT and IL-6 levels were significantly higher in group 1 (P-values of 0.003 and 0.006, respectively) but CRP levels were similar. An IL-6 cut-off point set at 310 pg ml−1 yielded a sensitivity of 90% and a specificity of 58% to differentiate group 1 patients from group 2 patients. When associated with the occurrence of SIRS on day 1 these values reached 100% and 79%, respectively. A PCT cut-off point set at 1.1 ng ml−1 yielded a sensitivity of 81% and a specificity of 72%. When associated with the occurrence of SIRS on day 1, these values reached 100% and 86%, respectively. Conclusions PCT and IL-6 appear to be early markers of subsequent postoperative sepsis in patients undergoing major surgery for cancer. These findings could allow identification of postoperative septic complications.

Journal ArticleDOI
TL;DR: The positive impact of neuromuscular monitoring and reversal of neurmuscular block in routine anaesthetic practice is confirmed and strongly decreased during the last decade in this institution.
Abstract: Background To avoid postoperative residual neuromuscular block there is a need for a change in clinician's attitude towards monitoring and reversal. This study aims to evaluate changes of perioperative neuromuscular block management during the last decade in our institution and to quantify the incidence of postoperative residual neuromuscular block. Methods Patients receiving intermediate-acting neuromuscular blocking agents for scheduled surgical procedures during 3-month periods in 1995 ( n =435), 2000 ( n =130), 2002 ( n =101), and in 2004 ( n =218) were prospectively and successively enrolled in our study. The management of neuromuscular block in the operating room and the adequacy of the recovery were at the discretion of the anaesthesiologist. An attempt was made between each study period to promote a change in the management of neuromuscular block. In the post-anaesthesia care unit, train-of-four (TOF) stimulations were used to assess the presence of a residual neuromuscular block. Results Between 1995 and 2004 quantitative measurement and reversal of neuromuscular block in the operating room increased from 2 to 60% and from 6 to 42%, respectively ( P P P Conclusions During the last decade the incidence of residual neuromuscular block strongly decreased in our institution. It confirms the positive impact of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice.

Journal ArticleDOI
TL;DR: Perioperative plaque stabilization by pharmacological means may be as important in the prevention of PMI as an increase in myocardial oxygen supply or a reduction in myCardial oxygen demand.
Abstract: Perioperative myocardial infarction (PMI) is one of the most important predictors of short- and long-term morbidity and mortality associated with non-cardiac surgery. Prevention of a PMI is thus a prerequisite for an improvement in overall postoperative outcome. The aetiology of PMI is multifactorial. The perioperative period induces large, unpredictable and unphysiological alterations in coronary plaque morphology, function and progression, and may trigger a mismatch of myocardial oxygen supply and demand. With many diverse factors involved, it is unlikely that one single intervention will successfully improve cardiac outcome following non-cardiac surgery. A multifactorial, step-wise approach is indicated. Based on increasing knowledge of the nature of atherosclerotic coronary artery disease, and in view of the poor positive predictive value of non-invasive cardiac stress tests, and the considerable risk of coronary angiography and coronary revascularization in high-risk patients, the paradigm is shifting from an emphasis on extensive non-invasive preoperative risk stratification to a combination of selective non-invasive testing and aggressive pharmacological perioperative therapy. Perioperative plaque stabilization by pharmacological means may be as important in the prevention of PMI as an increase in myocardial oxygen supply or a reduction in myocardial oxygen demand.

Journal ArticleDOI
TL;DR: Replacing 65% of the estimated blood volume with gelatin in swine resulted in dilutional coagulopathy; subsequent fibrinogen administration improved clot formation and reduced blood loss significantly.
Abstract: Background This study was conducted to determine whether replacement of fibrinogen is useful in reversing dilutional coagulopathy following severe haemorrhage and administration of colloids. Methods In 14 anaesthetized pigs, approximately 65% of the estimated blood volume was withdrawn and replaced with the same amount of gelatin solution to achieve dilutional coagulopathy. Animals were randomized to receive either 250 mg kg−1 fibrinogen (n=7) or normal saline (n=7). A standardized liver injury was then inflicted to induce uncontrolled haemorrhage. Modified thrombelastography and standard coagulation tests were performed at baseline, after blood withdrawal, after dilution, after injection of the study drugs, and on conclusion of the protocol. Further, electron microscopy imaging of the blood clots was performed and blood loss after liver injury was determined. Results Severely impaired haemostasis was observed after haemodilution with gelatin substitution. With administration of fibrinogen, clot firmness and dynamics of clot formation reached baseline values. Median blood loss following liver injury was significantly less (P=0.018) in the fibrinogen-treated animals (1100 ml; 800–1400 ml) than in the placebo group (2010 ml; 1800–2200 ml). Conclusions Replacing 65% of the estimated blood volume with gelatin in swine resulted in dilutional coagulopathy; subsequent fibrinogen administration improved clot formation and reduced blood loss significantly.

Journal ArticleDOI
TL;DR: Current evidence on blood transfusions is reviewed to highlight 'hot topics' with respect to efficacy, outcome and risks, and to provide the reader with transfusion guidelines.
Abstract: Careful assessment of risks and benefits has to precede each decision on allogeneic red blood cell (RBC) transfusion. Currently, a number of key issues in transfusion medicine are highly controversial, most importantly the influence of different transfusion thresholds on clinical outcome. The aim of this article is to review current evidence on blood transfusions, to highlight ‘hot topics’ with respect to efficacy, outcome and risks, and to provide the reader with transfusion guidelines. In addition, a brief synopsis of transfusion alternatives will be given. Based on up-to-date information of current evidence, together with clinical knowledge and experience, the physician will be able to make transfusion decisions that bear the lowest risk for the patient.

Journal ArticleDOI
TL;DR: The incidence of nausea and excessive sedation decreased over the period 1980-99, but the incidence of vomiting, pruritus, and urinary retention did not, and Acute Pain Services should aim for incidences less than this standard of care.
Abstract: This review examines the evidence from published data concerning the tolerability (indicated by the incidence of nausea, vomiting, sedation, pruritis, and urinary retention), of three analgesic techniques after major surgery; intramuscular analgesia (i.m.), patient-controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of publications concerned with the management of postoperative pain and these indicators identified over 800 original papers and reviews. Of these, data were extracted from 183 studies relating to postoperative nausea and vomiting, 89 relating to sedation, 166 relating to pruritis, and 94 relating to urinary retention, giving pooled data which represent a total of more than 100 000 patients. The overall mean (95% CI) incidence of nausea was 25.2 (19.3–32.1)% and of emesis was 20.2 (17.5–23.2)% for all three analgesic techniques. PCA was associated with the highest incidence of nausea but the emesis was unaffected by analgesic technique. There was considerable variability in the criteria used for defining sedation. The overall mean for mild sedation was 23.9 (23–24.8)% and for excessive sedation was 2.6 (2.3–2.8)% for all three analgesic techniques (significantly lower with epidural analgesia). The overall mean incidence of pruritus was 14.7 (11.9–18.1)% for all three analgesic techniques (lowest with i.m. analgesia). Urinary retention occurred in 23.0 (17.3–29.9)% of patients (highest with epidural analgesia). The incidence of nausea and excessive sedation decreased over the period 1980–99, but the incidence of vomiting, pruritis, and urinary retention did not. From these published data it is possible to set standards of care after major surgery for nausea 25%, vomiting 20%, minor sedation 24%, excessive sedation 2.6%, pruritis 14.7%, and urinary retention requiring catheterization 23%. Acute Pain Services should aim for incidences less than this standard of care.

Journal ArticleDOI
TL;DR: This is the first of two extracts from Why Mothers Die 2000-2002, issued on 12 November 2004 by the Confidential enquiry into Maternal and Child Health (CEMACH), reproduced with permission.
Abstract: This is the first of two extracts from Why Mothers Die 2000–2002, issued on 12 November 2004 by the Confidential enquiry into Maternal and Child Health (CEMACH), reproduced with permission. The full report can be accessed via their web site: http://www.cemach.org.uk/

Journal ArticleDOI
TL;DR: Although all attempts to demonstrate that regional anaesthesia and analgesia decrease postoperative mortality are unsuccessful, there is evidence supporting a reduction in pulmonary complications after major abdominal surgery, and an improvement in patient rehabilitation after orthopaedic surgery.
Abstract: Postoperative symptoms and complications can be prevented by a suitable choice of anaesthetic and analgesic technique for specific procedures. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side-effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for the use of rehabilitation programmes to accelerate recovery from surgery. Thus, combining opioid and/or non-opioid analgesics with regional analgesic techniques not only improves analgesic efficacy but also reduces opioid demand and side-effects such as nausea and vomiting, sedation, and prolongation of postoperative ileus. Although all attempts to demonstrate that regional anaesthesia and analgesia decrease postoperative mortality are unsuccessful, there is evidence supporting a reduction in pulmonary complications after major abdominal surgery, and an improvement in patient rehabilitation after orthopaedic surgery. When such techniques are used, cost–benefit analysis should be considered to determine suitable analgesic protocols for specific surgical procedures.

Journal ArticleDOI
TL;DR: It is shown that rFVIIa significantly reduces the need for allogeneic transfusion in complex non-coronary cardiac surgery without causing adverse events.
Abstract: Background. Receiving an allogeneic transfusion may be an independent predictor of mortality for patients undergoing cardiac surgery. Furthermore, these patients utilize 15% of all donated blood in the UK. In our unit, 80% of patients undergoing complex non-coronary cardiac surgery requiringcardiopulmonarybypass(CPB) receive anallogeneictransfusion.Activatedrecombinant FVII (rFVIIa) may be effective in reducing this need for transfusion. Methods. Twenty patients undergoing complex cardiac surgery were randomized to receive rFVIIa or placebo after CPB and reversal of heparin. Results.Two patients in the rFVIIa group received 13 units of allogeneic red cells and coagulation products compared with eight patients receiving 105 units of allogeneic red cells and coagulation products in the placebo group (relative risk of any transfusion 0.26; confidence interval 0.07‐0.9; P=0.037). The groups did not differ for adverse events. Conclusion.Despitemajor limitations(underpowered studyand proneto type Ierror), we have shown that rFVIIa significantly reduces the need for allogeneic transfusion in complex noncoronary cardiac surgery without causing adverse events.

Journal ArticleDOI
TL;DR: Evidence of a protective role for pharmacological preconditioning by sevoflurane in late cardiac events in CABG patients, which may be related to favourable transcriptional changes in pro- and antiprotective proteins, is provided.
Abstract: Background. Cardiac preconditioning is thought to be involved in the observed decreased coronary artery reocclusion rate in patients with angina preceding myocardial infarction. We prospectively examined whether preconditioning by sevoflurane would decrease late cardiac events in patients undergoing coronary artery bypass graft (CABG) surgery. Methods. Seventy-two patients scheduled for elective CABG surgery were randomized to preconditioning by sevoflurane (10 min at 4 vol%) or placebo. For all patients, follow-up of adverse cardiac events was obtained 6 and 12 months after surgery. Transcript levels for platelet–endothelial cell adhesion molecule-1 (PECAM-1/CD31), catalase and heat shock protein 70 (Hsp70) were determined in atrial biopsies after sevoflurane preconditioning. Results. Pharmacological preconditioning by sevoflurane reduced the incidence of late cardiac events during the first year after CABG surgery (sevoflurane 3% vs 17% in the placebo group, log-rank test, P =0.038). One patient in the sevoflurane group and three patients in the placebo group experienced new episodes of congestive heart failure and three additional patients had coronary artery reocclusion. Perioperative peak concentrations for myocardial injury markers were higher in patients with subsequent late cardiac events [NTproBNP, 9031 (4125) vs 3049 (1906) ng litre −1 , P vs 0.46 (0.29) μg litre −1 , P Conclusions. This prospective randomized clinical study provides evidence of a protective role for pharmacological preconditioning by sevoflurane in late cardiac events in CABG patients, which may be related to favourable transcriptional changes in pro- and antiprotective proteins.

Journal ArticleDOI
TL;DR: Pre-oxygenation in sitting position significantly extends the tolerance to apnoea in obese patients when compared with the supine position.
Abstract: Background In obese patients, reduced functional residual capacity exacerbated by supine position might decrease the effectiveness of pre-oxygenation and the tolerance to apnoea. The aim of this study was to compare the effect of body posture during pre-oxygenation, sitting or supine, on its effectiveness in obese patients. Methods Forty obese patients (BMI ≥35 kg m−2) undergoing surgery with general anaesthesia were randomly assigned to one of two groups: Group 1 (sitting, n=20) or Group 2 (supine, n=20). In the predetermined body position, pre-oxygenation was achieved with eight deep breaths within 60 s and an oxygen flow of 10 litre min−1. After rapid sequence induction of anaesthesia in decubitus position, the trachea was intubated and the patient was left apneic and disconnected from the anaesthesia circuit until Spo2 decreased to 90%. The time taken for desaturation to 90% from the end of induction of anaesthesia was recorded. Arterial blood oxygen tension was measured before (baseline) and after pre-oxygenation. Values were compared with two-way anova and unpaired Student's t-test. Results Oxygen and carbon dioxide tensions were similar between groups, both at baseline and after pre-oxygenation. However, the mean time to desaturation to 90% was significantly longer in the sitting group compared with the supine group [mean (sd): 214 (28) vs 162 (38) s, P Conclusions Pre-oxygenation in sitting position significantly extends the tolerance to apnoea in obese patients when compared with the supine position.

Journal ArticleDOI
TL;DR: A quarter of the total mortality in hip fracture patients is definitely unavoidable, and death is probably only avoidable in about half of the unselected patients, which has important implications for the design of future outcome studies.
Abstract: Introduction. Patients with hip fractures are usually frail and elderly with a 30-day mortality in excess of 10% in European series. Perioperative morbidity is often multifactorial in nature, and unimodal interventions will not necessarily decrease mortality. The purpose of this prospective study was to analyse causes of mortality, and thereby the potential and limitations to decrease mortality after hip fracture surgery. Methods. 300 consecutive, unselected hip fracture patients were treated in a multimodal rehabilitation programme with continuous perioperative epidural analgesia and anaesthesia, early surgery, standardized fluid and transfusion therapy, enforced oral nutrition and early mobilization and physiotherapy. All deaths within 30 days of surgery or during primary hospitalization were analysed and classified according to whether death was unavoidable, probably unavoidable, or potentially avoidable. Results. Thirty-day mortality was 13.3% (40 patients) and the total perioperative mortality was 15.6% (47 patients). Death was definitely unavoidable in 28%, probably unavoidable in 15%, and in theory potentially avoidable in 57%. In the patients where death was potentially avoidable, active care was curtailed in 16 of 27 (59%) patients. Conclusion. About a quarter of the total mortality in hip fracture patients is definitely unavoidable, and death is probably only avoidable in about half of the unselected patients. These results have important implications for the design of future outcome studies, which should focus on other relevant outcomes than mortality per se.

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TL;DR: In this article, the authors used a thrombelastographic method employing activation with tissue factor to obtain real-time whole blood (WB) clot formation profiles, which were transformed into dynamic velocity profiles of WB clot formation.
Abstract: Background. Plasma substitutes such as hydroxyethyl starch (HES) and various dextrans may compromise the haemostatic system, thereby causing potentially dangerous bleeding. Whilst several mechanisms have been advanced to explain the nature of the coagulopathy induced by this colloid, there has been comparably little interest in devising ways to optimize haemostasis after a relative colloid overdose. Methods. Real-time whole blood (WB) clot formation profiles were recorded using a thrombelastographic method employing activation with tissue factor. The coagulation tracings were transformed into dynamic velocity profiles of WB clot formation. WB from healthy individuals (n=20) was exposed to haemodilution of ∼55% with isotonic saline, HES 200/0.5, HES 130/0.4, and dextran 70, respectively. Possible modalities for improvement of the induced coagulopathy were explored, in particular ex vivo addition of a fibrinogen concentrate. Results. WB coagulation profiles changed significantly with decreased clot strength, and a compromised propagation phase of clot formation. The duration of the initiation phase of WB coagulation was unchanged. No statistical differences were detected amongst the HES solutions and dextran 70. However, dextran 70 returned a more suppressed clot development and strength compared with the HES solutions. Ex vivo haemostatic addition of washed platelets (75 ×109 litre−1) and factor VIII (0.6 IU ml−1) produced insignificant changes in clot initiation, propagation, and in the clot strength. In contrast, ex vivo addition of a fibrinogen concentrate (1 g litre−1) improved the coagulopathy induced by all of the three individual plasma expanders tested. Conclusion. Coagulopathy induced by haemodilution with either HES 200/0.5, HES 130/0.4, and dextran 70 may be improved by fibrinogen supplementation.

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TL;DR: Propacetamol, administered as a 15-min infusion, is a fast-acting analgesic agent that is more effective in terms of onset of analgesia than a similar dose of oral acetaminophen.
Abstract: Background The purpose of this randomized double-blind study was to compare the efficacy and safety of propacetamol 2 g (an i.v. acetaminophen 1 g formulation) administered as a 2-min bolus injection (n=50) or a 15-min infusion (n=50) with oral acetaminophen 1 g (n=50) or placebo (n=25) for analgesia after third molar surgery in patients with moderate to severe pain after impacted third molar removal. Methods All patients were evaluated for efficacy during the initial 6 h period after treatment administration (T0) and for safety during the entire week after T0. Results The onset of analgesia after propacetamol was shorter (3 min for bolus administration, 5 min for 15-min infusion) than after oral acetaminophen (11 min). Active treatments were significantly better for all parameters (pain relief, pain intensity, patient's global evaluation, duration of analgesia) than placebo (P Conclusion I.V. propacetamol, administered as a 15-min infusion, is a fast-acting analgesic agent. It is more effective in terms of onset of analgesia than a similar dose of oral acetaminophen.

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TL;DR: Both neonates and infants are able to mount a graded hormonal stress response to surgical interventions and adequate intraand postoperative analgesia will not only modify the stress response but has also been shown to reduce morbidity and mortality.
Abstract: The structural components necessary to perceive pain are already present at about 25 weeks gestation whereas the endogenous descending inhibitory pathways are not fully developed until mid-infancy. 4 164 Opioid and other receptors are much more widely distributed in fetuses and neonates. 53 62 66 127 Fetuses subjected to intrauterine exchange transfusion with needle transhepatic access will show both behavioural signs of pain as well as a hormonal stress response. Significant pain stimulation without proper analgesia, for example circumcision, will not only cause unacceptable pain at the time of the intervention but will produce a ‘pain memory’ as illustrated by an exaggerated pain response to vaccination as long as 6 months following the circumcision. Both neonates and infants are able to mount a graded hormonal stress response to surgical interventions and adequate intraand postoperative analgesia will not only modify the stress response but has also been shown to reduce morbidity and mortality. 3 5 6 16 17 163 167

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TL;DR: Application of a semi-rigid cervical collar can significantly reduce mouth opening and this could hinder definitive airway placement and support removing the anterior portion of the collar before attempts at tracheal intubation.
Abstract: Background Reduced mouth opening may be a major contributing factor to the deterioration in the view obtained at laryngoscopy when a semi-rigid cervical collar is in place. We set out to assess the degree to which mouth opening is restricted by a cervical collar. Methods We measured maximal inter-incisor distance in 52 volunteers. It was measured again after application of each of three appropriately sized semi-rigid cervical collars (Stifneck, Miami J, and Philadelphia). Results Inter-incisor distance was significantly reduced by the application of a cervical collar [No collar 41 (7) mm–mean (sd); Stifneck 26 (8) P P P Conclusions Application of a semi-rigid cervical collar can significantly reduce mouth opening. This could hinder definitive airway placement. Our results support removing the anterior portion of the collar before attempts at tracheal intubation.

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TL;DR: In 11 women there was a partial or good response to rFVIIa administration, while in one there was no response, and in the four women undergoing a subsequent selective arterial embolization, the bleeding was significantly reduced although not completely stopped.
Abstract: The treatment of life-threatening post-partum haemorrhage (PPH) still remains challenging, and hysterectomy may be required to control the bleeding. We present 12 cases of severe PPH treated with recombinant factor VIIa (rFVIIa). We briefly describe the causes of the haemorrhage and the medical and surgical interventions before rVIIa administration. In 11 women there was a partial or good response to rFVIIa administration, while in one there was no response. In the four women undergoing a subsequent selective arterial embolization, the bleeding was significantly reduced although not completely stopped. From our experience with these 12 cases, and from previously reported cases, the use of rFVIIa may be of benefit in life-threatening PPH. However, treatment with rFVIIa, in addition to standard surgical and medical interventions, may not be definitive in every patient and a selective arterial embolization may be needed.