Anaesthesia
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Non-technical skills are recognised as crucial to good anaesthetic practice. We designed and evaluated a specialty-specific tool to assess non-technical aspects of trainee performance in theatre, based on a system previously found reliable in a recruitment setting. We compared inter-rater agreement (multir-ater kappa) for live assessments in theatre with that in a selection centre and a video-based rater training exercise. ⋯ A subsequent assessor training exercise showed good inter-rater agreement, (mean kappa = 0.79) but did not improve performance of the assessment tool when used in round 2 (mean kappa = 0.14, G = 0.42). Inter-rater agreement in two selection centres (mean kappa = 0.61 and 0.69) exceeded that found in theatre. Assessment tools that perform reliably in controlled settings may not do so in the workplace.
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The objective of this study was to identify whether pulmonary capillary wedge pressure can be estimated in anaesthetised patients receiving mechanical ventilation, using transoesophageal echocardiography. A retrospective validation study investigated a 10-patient cohort with variable haemodynamic conditions, and a 102-patient series in which a single measurement was made during stable haemodynamic conditions. ⋯ In all cases, the limits of agreement exceeded 10 mmHg, and sensitivity or specificity for detecting wedge pressure ≥ 15 mmHg was poor. This study demonstrates proof of concept that using transoesophageal echocardiography for estimating the pulmonary artery wedge pressure may not be sufficiently accurate for clinical use.
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Dual-lumen haemodiafiltration catheters enable continuous renal replacement therapy in the critically ill and are often co-located with central venous catheters used to infuse drugs. The extent to which infusions are immediately aspirated by an adjacent haemodiafiltration catheter remains unknown. A bench model was constructed to evaluate this effect. ⋯ No tracer was aspirated from catheters infusing at least 2 cm downstream. Orientation of side ports did not affect tracer elimination. Co-location of central venous and haemodiafiltration catheters may lead to complete aspiration of infusions into the haemodiafilter with resultant drug under-dosing.
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We speculated that asymptomatic patients undergoing routine surgery might be at higher risk of subsequent cardiac events. We studied 183,534 patients with no prior admission for heart disease, aged 50-75 years, admitted electively for one of five operations considered medium to low risk of peri-operative cardiac morbidity, between January 1997 and December 2005. Controls were generated from linked records. ⋯ Of patients undergoing surgery, 20.2% died compared with 25.7% of controls (p < 0.001). Patients undergoing certain surgical procedures did not have a higher incidence of readmission for cardiac events, but had a general survival benefit compared with other elective hospital admissions. Assessment for surgery may represent a health benefit beyond the original surgery.
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Case Reports
Spinal anaesthesia for caesarean delivery in a parturient with babesiosis and Lyme disease.
We present a case of a parturient with babesiosis and Lyme disease who was scheduled for elective caesarean section. The caesarean section was performed under spinal anaesthesia, and the patient had a coronary artery dissection 4 days postoperatively. Neuraxial anaesthesia and possible mechanisms for the coronary artery dissection in a patient with babesiosis and Lyme disease are discussed.