British journal of anaesthesia
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Editorial Review
Perioperative database research: possibilities and pitfalls.
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Antifibrinolytic drugs have become almost ubiquitous in their use during major surgery when bleeding is expected or commonplace. Inhibition of the fibrinolytic pathway after tissue injury has been consistently shown to reduce postoperative or traumatic bleeding. There is also some evidence for a reduction of perioperative blood transfusion. ⋯ In the UK, tranexamic acid, a tissue plasminogen and plasmin inhibitor, is most commonly used, with evidence for benefit in cardiac, orthopaedic, urological, gynaecological, and obstetric surgery. In the USA, ε-aminocaproic acid, which also inhibits plasmin, is commonly used. We have reviewed the current literature for this increasingly popular class of drugs to support clinical judgement in daily anaesthetic practice.
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Review Meta Analysis
Cricoid pressure training using simulation: a systematic review and meta-analysis.
Cricoid pressure (CP) is commonly applied during rapid sequence intubation and may be protective during induction of anaesthesia; however, CP application by untrained practitioners may not be performed optimally. The objective of this systematic review was to synthesize the evidence regarding effectiveness of technology-enhanced simulation training to improve efficacy of CP application. Electronic databases from inception through May 11, 2011 were searched. ⋯ Comparative effectiveness research shows beneficial effects to force feedback training over training without feedback. Simulation training significantly improves the efficacy of CP application. Future studies might evaluate the clinical impact of training on CP application during rapid sequence intubation, and the comparative effectiveness of different training approaches.
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The hypothalamic-pituitary-adrenal (HPA) axis is a neuro-endocrine system that regulates circulating levels of glucocorticoid hormones. These hormones are vital for normal homeostasis and play a pivotal role in the response to stress. Levels of cortisol fluctuate throughout the day in a diurnal rhythm, underlying which is an ultradian rhythm of approximately hourly pulses, and this pulsatility directly affects transcriptional outcomes. ⋯ Levels of cortisol in both normal and illness states are highly dynamic and so previously used static assessment tools for diagnosing corticosteroid related critical illness insufficiency (CRCI) are not likely to be useful. Therapeutic regimens have also failed so far, to take secretory patterns into account. In this review we look at the dynamic control and effects of glucocorticoids and frame in this context the current evidence surrounding steroid use in critical care and major surgery.
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Cerebral blood flow (CBF) is regulated by vasomotor, chemical, metabolic, and neurogenic mechanisms. Even though the innervation of cerebral arteries is quite extensively described and reviewed in the literature, its role in regulation of CBF in humans remains controversial. We believe that insufficient attention has so far been focused on the potential role of the innervation of the cerebral vasculature in cerebral autoregulation in humans. ⋯ We postulate that under normal physiological conditions neurogenic control has little influence on cerebral autoregulation as other methods of control (vasomotor, chemical, and metabolic) are dominant. In severely challenging circumstances, such as delayed cerebral ischaemia after subarachnoid haemorrhage, these methods might be overwhelmed, increasing the relative importance of neurogenic, sympathetic control of CBF. This insight might lead to future therapeutic possibilities.