Anaesthesia
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Cardiovascular complications are an important cause of morbidity and mortality after non-cardiac surgery. Pre-operative identification of high-risk individuals and appropriate peri-operative management can reduce cardiovascular risk. It is important to continue chronic beta-blocker and statin therapy. ⋯ Aspirin continuation can increase the risk of major bleeding and offset the benefit of reduced myocardial risk. Contrary to the initial ENIGMA study, nitrous oxide does not seem to increase the risk of myocardial injury. Volatile anaesthetic agents and opioids have been shown to be cardioprotective in animal laboratory studies but these effects have, so far, not been conclusively reproduced clinically.
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Postoperative increases in serum creatinine concentration, by amounts historically viewed as trivial, are associated with increased morbidity and mortality. Acute kidney injury is common, affecting one in five patients admitted with acute medical disease and up to four in five patients admitted to intensive care, of whom one in two have had operations. ⋯ In the main, there are no interventions that directly treat the damaged kidney. The management of acute kidney injury is based on correction of dehydration, hypotension, and urinary tract obstruction, stopping nephrotoxic drugs, giving antibiotics for bacterial infection, and commencing renal replacement therapy if necessary.
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Accurate assessment of intravascular fluid status and measurement of fluid responsiveness have become increasingly important in peri-operative medicine and critical care. The objectives of this systematic review and narrative synthesis were to discuss current controversies surrounding fluid responsiveness and describe the merits and limitations of the major cardiac output monitors in clinical use today in terms of usefulness in measuring fluid responsiveness. We searched the MEDLINE and EMBASE databases (2002-2015); inclusion criteria included comparison with an established reference standard such as pulmonary artery catheter, transthoracic echocardiography and transoesophageal echocardiography. ⋯ Due to heterogeneity of the methods and patient characteristics, we did not perform a meta-analysis. In most studies, precision and limits of agreement (bias ±1.96SD) between determinants of fluid responsiveness measured by different devices were not evaluated, and the definition of fluid responsiveness varied across studies. Future research should focus on the physiological principles that underlie the measurement of fluid responsiveness and the effect of different volume expansion strategies on outcomes.
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Randomized Controlled Trial Comparative Study
Nasotracheal intubation in patients with limited mouth opening: a comparison between fibreoptic intubation and the Trachway(®).
In patients with limited mouth opening, traditional laryngoscopy and videolaryngoscopes are not useful when performing nasotracheal intubation. Eighty patients with limited mouth opening who required nasotracheal intubation were randomly assigned to either fibreoptic intubation (n = 40) or the Trachway(®) (n = 40). ⋯ Mean (SD) total intubation time was 71.8 (23.3) s in patients who received fibreoptic intubation compared with 35.4 (9.8) s in the Trachway group (p < 0.001). We conclude that the Trachway technique for nasotracheal intubation is quicker and easier compared with fibreoptic intubation in patients with limited mouth opening.