Anesthesiology
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Randomized Controlled Trial Comparative Study
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.
Accurately identifying the cricothyroid membrane is foundational for front-of-neck rescue of airway misadventure. Yet the very patients who are at risk of a cannot intubate, cannot oxygenate scenario (eg. obese, neck pathology) are also likely to make identifying the cricothyroid membrane (CTM) difficult.
Naveed and co. compared the accuracy of CTM palpation to ultrasound in a single-blinded randomized trial of 223 patients, with poorly defined landmarks, undergoing CT neck.
The ultrasound group showed a 10-time greater success in identifying the CTM (correct within 5 mm of actual; 81% vs 8%), along with a 5-times smaller mean distance from actual to estimated, than did the palpation group.
So what's the take home?
Given the wide-availability of ultrasound and it's acceptability to patients, any pre-induction marking of the CTM in an anticipated difficult airway should employ neck ultrasound in all but the most obviously-palpable necks.
In an emergent CICO situation, neck ultrasound likely has utility, though at the potential cost of procedural complexity and delay.
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Randomized Controlled Trial
Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients: A Subgroup Analysis of a Randomized Trial.
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients. ⋯ The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.
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Randomized Controlled Trial Comparative Study
Effect of Equipotent Doses of Propofol versus Sevoflurane Anesthesia on Regulatory T Cells after Breast Cancer Surgery.
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Clusters of differentiation 39 and 73, enzymes expressed on the surface of regulatory T cells, promote cancer recurrence and metastasis by suppressing immune cells. The authors hypothesized that propofol is less immunosuppressive than volatile anesthetics. The objective of this randomized trial was to compare the changes in cluster of differentiation 39 and 73 expression on regulatory T cells between propofol- and sevoflurane-based anesthesia during breast cancer surgery. ⋯ Changes in immune cells were similar with propofol and sevoflurane during breast cancer surgery. The effect of anesthetics on the perioperative immune activity may be minimal during cancer surgery.
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Randomized Controlled Trial
Caffeine Accelerates Emergence from Isoflurane Anesthesia in Humans: A Randomized, Double-blind, Crossover Study.
What did they do?
Using a randmoized, double-blind crossover study, Fong et al anaesthetized eight male volunteers twice with 1.2% isoflurane for 1 hour, after propofol induction. In the final 10 minutes subjects were randomized to IV caffeine or placebo. No opioids were administered.
Receiving IV caffeine hastened emergence by over 40%, as measured by BIS and psychomotor testing.
Return of gag reflex was used as the marker of emergence, although time to emergence was consistent with eye opening and BIS.
How much caffeine did they give?!?
15 mg/kg of caffeine citrate, equivalent to 7.5 mg/kg of base caffeine – the same caffeine as in two large cups of coffee for a 70 kg male.
Come on, surely this isn't that important?
Although the mean 7 min difference may not appear clinically significant, especially when using more modern volatiles, this study is a good proof of concept of how caffeine may be a useful clinical tool when faced with delayed emergence after anesthesia and for patients at greatest risk of persistent psychomotor depression post-anesthesia, such as the elderly.
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Randomized Controlled Trial
Preoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic Surgery: A Randomized Controlled Trial.
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Preoperative administration of epoetin-α with iron is commonly used in anemic patients undergoing major orthopedic surgery, but the optimal route of iron intake is controversial. The aim of this study was to compare the clinical effects of erythropoietin in combination with oral or intravenous iron supplementation. ⋯ After preoperative administration of erythropoietin, body iron stores and stimulation of the erythropoiesis were greater with intravenous ferric carboxymaltose than with oral ferrous sulfate supplementation.