Anaesthesia
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Randomized Controlled Trial
Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial.
Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. ⋯ There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0-14 [0-98]) mm vs. 14 (3-23 [0-64]) mm (p = 0.019); and on movement: 23 (10-51 [0-99]) mm vs. 44 (27-61 [2-94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.
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Patients eligible for emergency laparotomy who do not proceed to surgery are not as well characterised as patients who do proceed to surgery. We studied patients eligible for laparotomy, as defined by National Emergency Laparotomy Audit criteria, from August 2015 to October 2016. We analysed the association of individual variables with survival and two composite scores: P-POSSUM and a general survival model. ⋯ Our study supports the contention that survival beyond 30 postoperative days could be predicted reasonably accurately. Survival in patients who did not have laparotomy was shorter than expected. Emergency laparotomy might have prolonged survival in some patients.
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Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. ⋯ Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.
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The increasing age and subsequent medical complexity of patients presenting for surgery grants the opportunity to examine the processes and delivery of peri-operative care. There is a need to redesign peri-operative pathways allowing room for shared decision making and personalised, evidence-based care. In times of financial constraint, this is no easy task. ⋯ Challenges in redesigning peri-operative care pathways include identification and optimisation of those at highest peri-operative risk to inform the difficult conversations surrounding the appropriateness of surgery. The moral burden of these conversations on patient and professionals alike is increasingly recognised and managing this issue requires innovative models of collaborative, multidisciplinary and interprofessional working. To operate or not can be a challenging question to answer with a number of different perspectives to consider; not least that of the patient.
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An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to merge diverse skill sets. This needs not only physician and nursing leadership but also new models of care. ⋯ Shared decision-making is more likely to be manifest in a flat hierarchy in which each member of the team brings their own experience and skills to optimise patient care. Successful surgery is best achieved by a coordinated, multidisciplinary team, embedded in a culture of collaboration and safety.