Anaesthesia
-
Ventilator-induced lung injury (VILI) is the phenomenon by which mechanical ventilation exacerbates lung injury in critically ill patients. It is particularly relevant for those suffering from acute respiratory distress syndrome, in which the iatrogenic injury caused by VILI contributes to their high mortality. ⋯ However, it is our belief that the identification of inflammatory mediators that are crucial during VILI, and thus may make useful therapeutic targets, has become obscured by the wide variety of pre-clinical animal models of VILI reported in the literature. We aim here to summarise some of our work addressing this issue over the last 10 years, and thus, we hope, make interpretation of a convoluted field a little clearer.
-
Eighteen published trials have examined the use of neuraxial magnesium as a peri-operative adjunctive analgesic since 2002, with encouraging results. However, concurrent animal studies have reported clinical and histological evidence of neurological complications with similar weight-adjusted doses. The objectives of this quantitative systematic review were to assess both the analgesic efficacy and the safety of neuraxial magnesium. ⋯ The time to first analgesic request increased by 11.1% after intrathecal magnesium administration (mean difference: 39.6 min; 95% CI 16.3-63.0 min; p = 0.0009), and by 72.2% after epidural administration (mean difference: 109.5 min; 95% CI 19.6-199.3 min; p = 0.02) with doses of between 50 and 100 mg. Four trials monitored for neurological complications: of the 140 patients included, only a 4-day persistent headache was recorded. Despite promising peri-operative analgesic effect, the risk of neurological complications resulting from neuraxial magnesium has not yet been adequately defined.
-
During the past decade, there has been a dramatic increase in the number of thoracic surgical procedures carried out in the UK. The current financial climate dictates that more efficient use of resources is necessary to meet escalating demands on healthcare. One potential means to achieve this is through the introduction of enhanced recovery protocols, designed to produce productivity savings by driving reduction in length of stay. ⋯ We performed a comprehensive search for published work relating to the peri-operative management and optimisation of patients undergoing thoracic surgery, and divided these into appropriate areas of practice. We have reviewed the specific interventions that may be included in an enhanced recovery programme, including: pre-optimisation; minimising fasting time; thrombo-embolic prophylaxis; choice of anaesthetic and analgesic technique and surgical approach; postoperative rehabilitation; and chest drain management. Using the currently available evidence, the design and implementation of an enhanced recovery programme based on this review in selected patients as a package of care may reduce morbidity and length of hospital stay, thus maximising utilisation of available resources.
-
Review Comparative Study
A comparison of clinical practice guidelines for proximal femoral fracture.
Clinical practice guidelines are designed to assist clinical decision-making by summarising evidence and forming recommendations. The number of available guidelines is vast and they vary in relevance and quality. ⋯ This can result in a situation where the management of a particular clinical problem will depend upon which guideline is followed. We explore the reasons for such differences.