Anaesthesia
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Randomized Controlled Trial Comparative Study
A double-blind randomised comparison of intravenous patient-controlled remifentanil with intramuscular pethidine for labour analgesia.
In a prospective, double-blind, randomised controlled trial, we compared the efficacy of patient-controlled analgesia using remifentanil (25-30 μg per bolus) with intramuscular pethidine (50-75 mg) for labour analgesia in 69 parturients. Parturients receiving patient-controlled analgesia reported less pain than those receiving intramuscular pethidine throughout the study period (p < 0.001), with maximal reduction in visual analogue pain score at 2 h after commencement of analgesia (mean (SD) 20 (17) in the patient-controlled analgesia group and 36 (22) in the intramuscular pethidine group. The median (95% CI) time to the first request for rescue analgesics was significantly longer with patient-controlled analgesia (8.0 (6.8-9.2) h) compared with intramuscular pethidine (4.9 (3.8-5.4) h, p < 0.001). ⋯ There was no report of sedation, aponea or oxygen desaturation in either group, and Apgar scores were similar between groups. We conclude that patient-controlled analgesia with remifentanil provides better labour analgesia and maternal satisfaction than intramuscular pethidine. At this dose, maternal and fetal side effects were uncommon.
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Anticipated problems with airway management during anaesthesia require careful planning, particularly when they involve a risk of airway obstruction. Advice may be sought from published literature (usually written by experts) or through direct communication with experts. More frequently, expert involvement is through retrospective review following patient harm. ⋯ Some experts specifically criticised techniques that, unbeknown to them, were proposed by others. The case raises issues about the nature of expert opinion that extends beyond this particular case. The nature and implications of expert opinion, when evidence is absent or conflicting, are discussed.
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Increased tracheal cuff pressure during mechanical ventilation is associated with reduced mucosal blood flow and ischaemia, as well as postoperative sore throat. We assessed the potential effects of transoesophageal echocardiography probe insertion on the tracheal cuff pressure in patients undergoing cardiac surgery. ⋯ After probe insertion, the mean (SD) intra-cuff pressure increased from 27.7 (1.5) to 36.2 (6.4) cm H(2)O (p < 0.001) and was > 35 cm H(2)0 in 17/38 patients (45%). Our results suggest that transoesophageal echocardiography probe insertion may increase the tracheal cuff pressure more than that is generally recommended and therefore the latter should be routinely monitored under such circumstances.
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Focused transthoracic echocardiography by anaesthetists in the peri-operative period has recently been described; the data suggest that the specific skills required can be obtained by non cardiology physicians with limited training. Aortic stenosis is known to increase significantly the peri-operative risk in non-cardiac surgery. This study aimed to assess the ability of echocardiography naive trainee anaesthetists to recognise and assess the severity of aortic stenosis after a set amount of training. ⋯ There was 100% concordance between trainees and the consultant for assessment of clinically significant aortic stenosis, with no cases of misdiagnosis. There was also 90-100% agreement (kappa statistic 0.8-1) between the consultant and each trainee's assessment of clinically significant aortic stenosis based on a peak aortic velocity > 3 m.sec(-1). Anaesthesia trainees can be successfully and rapidly trained to recognise and estimate the severity of aortic stenosis.
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Letter Case Reports
Wrong site medical intervention: another potential source for error.