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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Randomized Controlled Trial
Addition of clonidine to a continuous patient-controlled epidural infusion of low-concentration levobupivacaine plus sufentanil in primiparous women during labour.
We studied the potentiation of analgesia for labour by the addition of clonidine to epidural low-concentration levobupivacaine with sufentanil in a randomised, double-blinded study. We enrolled primiparous women who were in spontaneous labour. The study solutions, made of 100 ml levobupivacaine 0.0625% plus sufentanil 0.45 μg.ml(-1) and either 150 μg clonidine or no clonidine, were used for induction of analgesia, and for its maintenance with self-administered boluses and a continuous background infusion. ⋯ Blood pressure was lower and the rate of instrumental delivery higher in the clonidine group. Clonidine (1.36 μg.ml(-1)) added to the epidural solution of low-concentration levobupivacaine improves the quality of analgesia. The relevance of the haemodynamic effects should be explored in larger validation studies.
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Randomized Controlled Trial Comparative Study
A comparison of pudendal block vs dorsal penile nerve block for circumcision in children: a randomised controlled trial.
We compared the analgesic and anaesthetic efficacy of pudendal nerve block with that of dorsal penile nerve block in male patients aged 3-5 years of age, undergoing elective circumcision. Thirty patients had a nerve stimulator-guided pudendal nerve block with two separate injection points 1.5-2 cm from the centre of the anus, and thirty patients received a dorsal penile nerve block. ⋯ The pudendal nerve group showed significantly lower postoperative pain scores than the dorsal group (SD) (p < 0.05), and significantly fewer patients consumed analgesics in the pudendal group than the dorsal group: 0 vs 5 (17%) at 0 and 6 h, respectively. This study demonstrates the effectiveness of pudendal nerve block in comparison to the dorsal nerve block, with improved postoperative outcomes in children undergoing circumcision.
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Hypothermia after elective cardiac surgery is an important physiological abnormality and is associated with increased morbidity and mortality. The Australian and New Zealand intensive care adult patient database was studied to obtain the lowest and highest temperature in the first 24 h after surgery. ⋯ Transient hypothermia was not independently associated with increased hospital mortality (OR = 0.9, 95% CI 0.8-1.1), whereas persistent hypothermia was associated with markedly increased risk of death (OR = 6.3, 95% CI = 3.3-12.0). Hypothermia is common in postoperative cardiac surgery patients during the first 24 h after ICU admission but, if transient, is not independently associated with an increased risk of death.
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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.