British journal of anaesthesia
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The cardiology literature has suggested for decades that β-blockade protects patients with ischaemic heart disease. Extending this concept to perioperative patients initially produced promising results, with reductions in perioperative myocardial ischaemia and longer-term cardiovascular complications observed in several small randomized trials. However, subsequent larger trials have either shown no benefit or greater morbidity (especially stroke), despite reductions in cardiovascular events. ⋯ Speciality societies, most importantly, the American Heart Association/American College of Cardiology Foundation, have promulgated guidelines for perioperative β-blockade, which have been revised, as the evidence has changed. While the European guidelines continue to emphasize perioperative β-blockade in high-risk patients, the American guidelines have reduced the strength and breadth of recommendations, focusing on haemodynamic titration. Future work will need to focus on identifying populations most likely to benefit or to be harmed, including pharmacogenetic analyses and distinctions between individual β-blockers.
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Many anaesthesia practitioners caring for patients with a cardiac implantable electronic device (CIED) lack the knowledge, experience, and requisite programming devices to independently manage these patients perioperatively. A recently updated ASA task force Practice Advisory presents expert opinion regarding the perioperative management of patients with CIEDs, and the Heart Rhythm Society (HRS) recently published a consensus statement on this subject in collaboration with the ASA, American Heart Association (AHA), and Society of Thoracic Surgeons (STS). The main intent of these documents is to provide recommendations that promote safe management of patients with CIEDs throughout the perioperative period and reduce the likelihood of adverse outcomes. ⋯ In emergent situations, however, or when there is no time for the requisite consultations, and in practice settings where the suggested multidisciplinary approach is simply not feasible, the anaesthesia team must still provide effective, safe perioperative management. Thus, all anaesthesiologists should become familiar with the basics of the current CIED technology and the essential tenets of perioperative CIED management. This review discusses relevant advances in CIED technology and practical perioperative management as outlined in the 2011 ASA Practice Advisory and HRS consensus statement.
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The actual incidence of neurological dysfunction resulting from haemorrhagic complications associated with neuraxial block is unknown. Although the incidence cited in the literature is estimated to be <1 in 150,000 epidural and <1 in 220,000 spinal anaesthetics, recent surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increases with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard unfractionated heparin or low molecular weight heparin). ⋯ Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal haematoma. Vigilance in monitoring is critical to allow early evaluation of neurological dysfunction and prompt intervention. An understanding of the complexity of this issue is essential to patient management.
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Randomized Controlled Trial
Randomized controlled trial of the A.P. Advance, McGrath, and Macintosh laryngoscopes in normal and difficult intubation scenarios: a manikin study.
Several videolaryngoscopes are available which may facilitate tracheal intubation in difficult airways. We compared the McGrath(®) Series 5 and the Venner™ A.P. Advance™ (APA) videolaryngoscopes with a Macintosh laryngoscope by studying the performance of experienced anaesthetists using manikins in normal and difficult airway scenarios. ⋯ Experienced anaesthetists required a longer time for intubation in a standard manikin using a McGrath compared with other laryngoscopes, but a shorter time for intubation in a difficult manikin using an APA with DAB, and with fewer glottic advances, compared with other laryngoscopes.
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Increasing numbers of older patients prescribed clopidogrel are presenting for urgent hip fracture surgery. Best practice for the management of clopidogrel therapy is unknown, although delays to surgery are associated with increased mortality. We investigated the influence of perioperative management of clopidogrel therapy on in-hospital cardiac morbidity and transfusion in this population. ⋯ The length of withdrawal of clopidogrel therapy perioperatively was associated with a significantly increased incidence of ACS. An association between shorter withdrawal and increased blood transfusion requirements was also seen. The study emphasizes the cardiovascular risks of routinely interrupting clopidogrel therapy in this at-risk population and that a more considered, individualized, evidenced-based approach is needed.