Anaesthesia
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Randomized Controlled Trial Comparative Study Clinical Trial
Sevoflurane: a comparison between vital capacity and tidal breathing techniques for the induction of anaesthesia and laryngeal mask airway placement.
Sixty unpremedicated adult day-case patients were randomly assigned to either vital capacity or tidal breathing inhalational induction techniques. End points assessed included loss of eyelash reflex, time to drop a weighted syringe, time to jaw relaxation and time to the end of laryngeal mask airway insertion. Complications occurring during the induction of anaesthesia were recorded. ⋯ Patient acceptance of both techniques was similarly high. When the time taken to prime the anaesthetic breathing system is taken into consideration, the vital capacity technique is more expensive for induction of anaesthesia. These results therefore question the need for the vital capacity induction technique with sevoflurane 8%.
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Randomized Controlled Trial Clinical Trial
Adrenocortical function in critically ill patients 24 h after a single dose of etomidate.
We compared the effects of single doses of etomidate and thiopentone on adrenocortical function in a randomised controlled clinical trial involving 35 critically ill patients who needed a general anaesthetic. Just before induction of anaesthesia, a baseline blood cortisol sample was taken. Twenty-four hours later we performed a short adrenocorticotrophic hormone stimulation test. ⋯ Baseline, pre-ACTH and post-ACTH cortisol levels were similar in the two groups. However, significantly more patients in the etomidate group had an ACTH-stimulated cortisol increment < 200 nmol.l-1. The clinical significance of these findings is not clear, but we conclude that single doses of etomidate may interfere with cortisol synthesis for at least 24 h in the critically ill.
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Randomized Controlled Trial Clinical Trial
Effect of epidural bupivacaine on the relationship between the bispectral index and end-expiratory concentrations of desflurane.
We compared the relationship between the bispectral index and end-tidal desflurane concentrations in 20 patients undergoing elective surgery. Patients received epidurally either 10 ml saline (group S) or 10 ml bupivacaine 0.125% with epinephrine 1/800 000 (group B) before induction of anaesthesia with sufentanil (0.15 microgram.kg(-1)) and propofol (2 mg.kg(-1)); muscle relaxation was obtained with cisatracurium (0.2 mg.kg(-1)). Patients lungs were ventilated to maintain end-tidal desflurane at 3% in O2/N2O (50/50) until 5 min after skin incision, followed by two consecutive 10 min periods at end-tidal desflurane 6% and 9%. bispectral index values were recorded before induction, at 3% desflurane before and 5 min after skin incision, and at 6% and 9% end-tidal desflurane. ⋯ The relationship between bispectral index and end-tidal desflurane concentration was fitted by a linear regression in each group. No significant difference in bispectral index was observed between the groups at any time. We conclude that bispectral index decreases with increasing desflurane concentration and that this relationship is not affected by epidural 0.125% bupivacaine.
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A 'patient-at-risk team', established to allow the early identification of seriously ill patients on hospital wards, made 69 assessments on 63 patients over 6 months. Predefined physiological criteria were not able to reliably predict which patients would be admitted to the intensive care unit. The incidence of cardiopulmonary resuscitation before intensive care admission was 3.6% for patients seen by the team and 30.4% for those not seen (p < 0.005). ⋯ Among those not seen by the team, mortality was 40% for those who did not require resuscitation and 57% for those who did (not significant). Many critically ill ward patients had abnormal physiological values before intensive care unit admission. Identification of critically ill patients on the ward and early advice and active management are likely to prevent the need for cardiopulmonary resuscitation and to improve outcome.
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Case Reports
The use of neuromuscular blocking agents in noncardiac surgery after dynamic cardiomyoplasty.
Dynamic cardiomyoplasty is a surgical treatment to improve cardiac performance in patients with end-stage heart failure by wrapping the latissimus dorsi muscle around the heart. The use of skeletal muscle raises concerns about the safety of neuromuscular blocking agents used during general anaesthesia in noncardiac surgery in patients after cardiomyoplasty. ⋯ No clinically relevant effects on haemodynamics were observed. We conclude that the use of nondepolarising neuromuscular blocking agents for noncardiac surgery in patients after cardiomyoplasty does not compromise cardiac performance in a clinically relevant way, although the time between the cardiomyoplasty procedure and the use of nondepolarising neuromuscular blocking agents remains a concern.