Anaesthesia
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Randomized Controlled Trial
A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition.
This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. ⋯ Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication.
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High-sensitivity C-reactive protein (hsCRP) adds important prognostic information, not reflected by traditional risk factors, to the prediction of both the development and outcome of cardiovascular pathology. HsCRP levels also correlate inversely with cardiorespiratory fitness, an important determinant of peri-operative outcome. We hypothesised that pre-operative hsCRP should be associated with excess peri-operative morbidity and longer length of stay. ⋯ Higher pre-operative hsCRP was associated with longer length of stay: mean 7.5 days (95% CI: 6.2-8.8) vs 6.0 days (95% CI: 5.5-6.5; p = 0.03; log rank test). In 21 patients with > 8 days length of stay, high pre-operative hsCRP patients were over-represented (p = 0.04). Pre-operative hsCRP is related to length of stay and delayed postoperative complications.
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Randomized Controlled Trial Comparative Study
A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery.
In a randomised double blind prospective study, we tested the hypothesis that postoperative pain is lower in patients who receive an ProSeal LMA laryngeal mask airway compared with a tracheal tube. One hundred consecutive female patients (ASA I-II, 18-75 years) undergoing laparoscopic gynaecological surgery were divided into two equal-sized groups for airway management with the ProSeal LMA or tracheal tube. Anaesthesia management was identical for both groups and included induction of anaesthesia using propofol/fentanyl, and maintenance with propofol/remifentanil, muscle relaxation with rocuronium, positive pressure ventilation, gastric tube insertion, dexamethasone/tropisetron for anti-emetic prophylaxis, and diclofenac for pain prophylaxis. ⋯ Nausea was less common with the ProSeal LMA than with the tracheal tube at 2 h and 6 h but not at 24 h. There were no differences in the frequency of vomiting, sore throat, dysphonia or dysphagia. We conclude that postoperative pain is lower for the ProSeal LMA than the tracheal tube in females undergoing gynaecological laparoscopic surgery.
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The TruView EVO2 laryngoscope was compared with the traditional Macintosh laryngoscope in 200 patients who required tracheal intubation for elective surgery. Mallampati score determined prior to laryngoscopy was significantly related to the view of the glottis during laryngoscopy for both laryngoscopes. The view of the larynx was better with the TruView EVO2 laryngoscope than with the Macintosh laryngoscope in patients with a Cormack and Lehane grade greater than 1 (p < 0.01). The mean time to intubate was significantly shorter with the Macintosh laryngoscope (34 s) than with the TruView laryngoscope (51 s) (p < 0.01).
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Multicenter Study
The concept of surgical operating list 'efficiency': a formula to describe the term.
While numerous reports have sought ways of improving the efficiency of surgical operating lists, none has defined 'efficiency'. We describe a formula that defines efficiency as incorporating three elements: maximising utilisation, minimising over-running and minimising cancellations on a list. We applied this formula to hypothetical (but realistic) scenarios, and our formula yielded plausible descriptions of these. ⋯ Again, the formula gave useful insights into problems faced by the teams in improving their performance, and it also guided possible solutions. The formula confirmed that a team that schedules cases according to the predicted durations of the operations listed (i.e. the non-university hospital team) suffered fewer cancellations (median 5% vs 8% and 13%) and fewer list over-runs (6% vs 38% and 50%), and performed considerably more efficiently (90% vs 79% and 72%; p = 0.038) than teams that did not do so (i.e. those from the university hospital). We suggest that surgical list performance is more completely described by our formula for efficiency than it is by other conventional measures such as list utilisation or cancellation rate alone.