Anaesthesia
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High-flow nasal oxygen is increasingly used for oxygenation during apnoea. Extending apnoea duration using this technique has mainly been investigated during minor laryngeal surgery, but it is unclear how long it can be administered for before it should be discontinued due to acidosis. We aimed to describe the dynamics of arterial blood gases during apnoeic oxygenation with high-flow nasal oxygen with jaw thrust only, to explore the limits of this technique. ⋯ The mean (SD) PaCO2 increase was 0.25 (0.06) kPa.min-1 but it varied substantially (range 0.13-0.35 kPa.min-1 ). Mean (SD) arterial oxygen tension was 48.6 (11.8) kPa when high-flow nasal oxygen was stopped. Patients with apnoea time > 25 minutes were significantly older (p = 0.025). We conclude that apnoeic oxygenation with high-flow nasal oxygen resulted in a significant respiratory acidosis that varies substantially on the individual level, but oxygenation was maintained.
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Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3 , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. ⋯ Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.
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Interventions from randomised controlled trials can only be replicated if they are reported in sufficient detail. The results of trials can only be confidently interpreted if the delivery of the intervention was systematic and the protocol adhered to. We systematically reviewed trials of anaesthetic interventions published in 12 journals from January 2016 to September 2019. ⋯ Intervention standardisation was reported for 135 (83%) out of the 162 interventions, and protocol adherence was reported for 20 (12%) interventions. Sixty (77%) out of the 78 trials reported the administrative context in which interventions were delivered and 36 (46%) trials detailed the expertise of the practitioners. We conclude that bespoke reporting tools should be developed for anaesthetic interventions and interventions in other areas such as critical care.
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Pre-operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri-operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. ⋯ In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non-anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri-operative risk to non-anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real-world setting.
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Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. ⋯ They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.