Anaesthesia
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The word 'trauma' describes the disease entity resulting from physical injury. Trauma is one of the leading causes of death worldwide and deaths due to injury look set to increase. As early as the 1970s, it became evident that centralisation of resources and expertise could reduce the mortality rate from serious injury and that organisation of trauma care delivery into formal systems could improve outcome further. ⋯ Similar systems exist internationally and continue to be developed. Anaesthetists have been and continue to be involved with all levels of trauma care delivery, from the provision of pre-hospital trauma and retrieval teams, through to chronic pain management and rehabilitation of patients back into society. This review examines the international development of major trauma care delivery and the components of a modern trauma system.
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In this second article we examine the principles underlying delivery of the components of anaesthesia. Topics considered include anaesthetic technique, management of the airway and lung ventilation, induction and maintenance of anaesthesia, patient monitoring including the place of cardiac output devices. We summarise recent research on the management of shock and sepsis syndromes including goal directed therapy and examine some controversies around intravenous fluid therapy. Finally, we discuss intra-operative awareness and challenges during emergence including peri-operative cognitive dysfunction.
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Patients presenting for emergency surgery represent a category at high risk of complications, with substantial morbidity and mortality, whose management may be extremely challenging. In this first of two articles we consider the identification and evaluation of high risk emergency patients, the provision of critical care support, the management of sepsis, common postoperative complications and in-theatre death.
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In this, the first of two article on medical emergencies, we discuss the definitions, epidemiology, pathophysiology, acute and chronic management of atrial fibrillation and acute myocardial necrosis in the peri-operative and intensive care settings.
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Paediatric patients who require anticoagulation with therapeutic doses of low-molecular weight heparin are at risk of having a residual anticoagulant effect at the time of surgery, even if managed according to current peri-operative guidelines. Testing for residual effect is not currently recommended in such circumstances. ⋯ Subsequently, thromboelastography was also used to monitor haemostatic therapy, which consisted of protamine 2 mg.kg(-1) and 500 IU cryoprecipitate. Thromboelastography was used intra-operatively to allow rapid testing of coagulation status and guide therapy, thereby minimising use of blood products and reducing complications.