Anaesthesia
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Although target-controlled infusion has been in use for more than two decades, its benefits are being obscured by anomalies in clinical practice caused by a number of important problems. These include: a variety of pharmacokinetic models available in open target-controlled infusion systems, which often confuse the user; the extrapolation of anthropomorphic data which provokes anomalous adjustments of dosing by such systems; and the uncertainty of regulatory requirements for the application of target-controlled infusion which causes uncontrolled exploitation of drugs and pharmacokinetic models in target-controlled infusion devices. ⋯ However, a specific behaviour of a model in a target-controlled infusion system that is neither intended nor supported by scientific data can be considered an artefact or anomaly. Several of these anomalies can be identified in the current commercially available target-controlled infusion systems and are discussed in this review.
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Observational Study
The association between borderline pre-operative anaemia in women and outcomes after cardiac surgery: a cohort study.
Anaemia is common before cardiac surgery and is associated with increased morbidity and mortality. The World Health Organization (WHO) definition of anaemia is lower for women than for men by 10 g.l-1 , potentially putting women at a disadvantage compared with men with regard to pre-operative optimisation. Our hypothesis was that women with borderline anaemia (defined by us as haemoglobin concentration 120-129 g.l-1 ) would have a higher rate of red cell transfusion, morbidity and mortality than non-anaemic women (haemoglobin ≥ 130 g.l-1 ). ⋯ Short- and long-term postoperative survival was comparable in both groups. Borderline anaemia is associated with increased red cell transfusion and prolonged hospital stay. Future research should address whether correction of borderline anaemia results in improved outcomes.
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Randomized Controlled Trial
The effect of anaesthetic technique during primary breast cancer surgery on neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and return to intended oncological therapy.
Inflammation and immunosuppression contribute to the pathogenesis of cancer. An increased neutrophil-lymphocyte ratio reflects these processes and is associated with adverse cancer outcomes. Whether anaesthetic technique for breast cancer surgery influences these factors, and potentially cancer recurrence, remains unknown. ⋯ Pre-operative neutrophil-lymphocyte ratio was similar in the propofol-paravertebral 2.3 (95%CI 1.8-2.8) and inhalational agent-opioid anaesthesia 2.2 (1.9-3.2) groups, p = 0.72. Postoperative neutrophil-lymphocyte ratio was lower (3.0 (2.4-4.2) vs. 4.0 (2.9-5.4), p = 0.001) in the propofol-paravertebral group. Propofol-paravertebral anaesthesia attenuated the postoperative increase in the neutrophil-lymphocyte ratio.
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The Cook staged extubation set (Cook Medical) has been developed to facilitate management of the difficult airway. A guidewire inserted before tracheal extubation provides access to the subglottic airway should re-intubation be required. This prospective cohort study examines patients' tolerance of the guidewire and its impact on clinical status around tracheal extubation in the intensive care unit. ⋯ Nasendoscopy was performed in 11 of these patients and revealed one wire was in the oesophagus. The most common symptom was a mild intermittent cough in 13 patients. There was no impact of the guidewire on nursing care in 16 patients, tolerable impact in five and severe impact necessitating removal of the wire in one patient.