Anaesthesia
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The effects of the combination of a 'lowest' lung ventilation with extracorporeal elimination of carbon dioxide by interventional lung assist are described in a patient presenting with severe acute respiratory distress syndrome due to fulminant pneumonia. Reducing tidal volume to 3 ml.kg(-1) together with interventional lung assist resulted in a decrease in severe hypercapnia without alveolar collapse or hypoxaemia but with a decrease in serum levels of interleukin-6. This approach was applied for 12 days with recovery of the patient, without complications. Extracorporeal removal of carbon dioxide by interventional lung assist may be a useful tool to enable 'ultraprotective' ventilation in severe acute respiratory distress syndrome.
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The purpose of this study was to determine the effect-site concentration of remifentanil that would provide optimal conditions for successful laryngeal mask airway insertion during a target-controlled infusion (TCI) of propofol at 3.5 microg.ml(-1) without the use of neuromuscular blockade. Five minutes after propofol infusion, remifentanil was infused at a dose determined by a modified Dixon's up-and-down method. ⋯ The effect-site concentration of remifentanil for successful laryngeal mask insertion in 50% of adults (EC(50)) was 3.04 (SD 0.49) ng.ml(-1) during a TCI of 3.5 microg.ml(-1) propofol without neuromuscular blockade. From the probit analysis, the EC(50) and EC(95) of remifentanil were 2.84 ng.ml(-1) (95% CI 2.09-3.57 ng.ml(-1)) and 3.79 ng.ml(-1) (95% CI 3.26-9.25 ng.ml(-1)), respectively.
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Randomized Controlled Trial
The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.
Trained assistance for the anaesthetist appears likely to improve safety in anaesthesia. However, there are few objective data to support this assumption, and the requirement for a trained assistant is not universally enforced. We applied a simulation-based model developed in previous work to test the hypothesis that the presence of a trained assistant reduces error in anaesthesia. ⋯ The mean (SD) error rate per scenario was 4.75 (2.9). There were significantly fewer errors in the technician group than the nurse group (33 vs 62, p = 0.01) and this difference remained significant when errors were weighted for severity. This provides objective evidence supporting the requirement for trained assistance to the anaesthetist, and furthermore, demonstrates that a simulation-based model can provide rigorous evidence on safety interventions in anaesthesia.
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Gathering evidence from animal experiments, an editorial in this journal and published human case reports culminated in the Association of Anaesthetists of Great Britain and Ireland recommending in August 2007 that lipid emulsion be immediately available to all patients given potentially cardiotoxic doses of local anaesthetic drugs. This development offered an opportunity to track the adoption of an innovation by anaesthetists in the UK and to gauge the effects of guidelines. Two surveys, each of 66 NHS hospitals delivering acute care within London and its penumbra, examined the adoption of lipid emulsion therapy. ⋯ At the end of 2007, there remained a small number of hospitals that had yet to adopt lipid rescue. Lipid rescue's adoption by anaesthetists in the UK offers a rare example of swift uptake of an innovation. National guidelines accelerated the adoption of innovation by some hospitals.
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Anaesthetists are legally obliged to obtain informed consent before performing regional analgesia in labour. A postal survey of consultant-led UK anaesthetic units was performed in September 2007 to assess practice regarding obtaining informed consent before inserting an epidural, and documentation of the risks discussed. ⋯ There was great variation between units regarding which risks women were informed about and the likely incidence of that risk. One hundred and twenty-three respondents out of 157 providing an epidural service (78%) supported a national standardised information card endorsed by the Obstetric Anaesthetists' Association, with all the benefits and risks stated, to be shown to all women before consenting to an epidural in labour.