British journal of anaesthesia
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The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. ⋯ However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.
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Comparative Study
Cerebral haemodynamics in pregnancy and pre-eclampsia as assessed by transcranial Doppler ultrasonography.
Altered cerebral circulation, as reported during normal pregnancy, and in patients with pre-eclampsia, can be associated with changes in cerebral vascular reactivity and/or cerebral autoregulation. The aim of our study was to perform a comparative assessment of cerebral haemodynamics, including vascular reactivity and autoregulation, in pre-eclamptic patients, healthy pregnant women, and healthy non-pregnant women. ⋯ Healthy pregnancy increases eCPP, presumably by decreasing CrCP. In pre-eclampsia, eCPP is maintained at the same level as in healthy pregnancy despite an increased MAP. Pre-eclampsia has no significant effect on cerebral autoregulation or CRCO(2).
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Head-down tilt is often used to assist cannulation of the internal jugular vein (IJV). However, the optimal duration of tilt before cannulation is not well defined. ⋯ The 10 degrees head-down tilt manoeuvre in healthy volunteers causes an immediate, significant increase in CSA in the right IJV. A longer tilt did not cause further increase in jugular CSA.
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We present the cases of three women who, within a 6-month period, suffered post-partum generalized tonic-clonic seizures. All had received an epidural in labour for analgesia and were subsequently diagnosed as suffering from postdural puncture headache. ⋯ All made satisfactory recoveries and were discharged home. None displayed classical patterns suggestive of pre-eclampsia, meningitis, cortical venous thrombosis or any other pathological process that might explain these events adequately, and the specific precipitating factors were left unidentified.
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The laryngeal tube is a new alternative for securing the airway. After adequate oxygenation, insertion of a tracheal tube is still required in many situations. In such circumstances, fibreoptic placement of a tube exchange catheter after placement of the laryngeal tube is possible before tracheal intubation. Throughout the procedure, oxygen administration can continue via the laryngeal tube, the tube exchange catheter and the tracheal tube. ⋯ This technique is an important alternative for airway management and provides a significant degree of patient safety.