British journal of anaesthesia
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Cryoprecipitate, originally developed as a therapy for patients with antihaemophilic factor deficiency, or haemophilia A, has been in use for almost 50 yr. However, cryoprecipitate is no longer administered according to its original purpose, and is now most commonly used to replenish fibrinogen levels in patients with acquired coagulopathy, such as in clinical settings with haemorrhage including cardiac surgery, trauma, liver transplantation (LT), or obstetric haemorrhage. Cryoprecipitate is a pooled product that does not undergo pathogen inactivation, and its administration has been associated with a number of adverse events, particularly transmission of blood-borne pathogens and transfusion-related acute lung injury. ⋯ Consequently, there is uncertainty over the appropriate dosing and optimal administration of cryoprecipitate, with some guidelines from professional societies to guide clinical practice. Randomized, controlled trials are needed to determine the clinical efficacy of cryoprecipitate, compared with the efficacy of alternative preparations. These trials will allow the development of evidence-based guidelines in order to inform physicians and guide clinical practice.
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Comparative Study
Percutaneous transtracheal ventilation in an obstructed airway model in post-apnoeic sheep.
Temporizing oxygenation by percutaneous transtracheal ventilation (PTV) is a recommended emergency technique in 'can't intubate, can't oxygenate' (CICO) situations. Barotrauma risk increases if expiration is obstructed. The Ventrain(®) is a new PTV device that assists expiration. Our aim was to compare key physiological outcomes after PTV with the Ventrain and the Manujet(®) in a large animal obstructed airway model. ⋯ The Ventrain provided stable oxygenation and effective ventilation at low airway pressures during emergency PTV in critically obstructed airways. The Manujet provided effective temporizing oxygenation in this situation with hypoventilation necessary to minimize barotrauma risk. The nature and extent of airway obstruction may not be known in a CICO emergency but an understanding of device differences may help inform optimal ventilation device and method selection.
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Observational Study
Survival after postoperative morbidity: a longitudinal observational cohort study†
Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent definitions of postoperative morbidity. ⋯ Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.
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Anaesthetic management of the acute stroke patient demands consideration of the penumbra as the central focus. Recent studies have shown that patients who receive general anaesthesia for endovascular therapy for acute ischaemic stroke have worse outcomes than those who receive local anaesthesia. ⋯ Keeping these factors in mind, anaesthetic technique (general, monitored anaesthesia care, or local) must be selected considering the individual patient's risks and benefits. Unfortunately, there are no proven neuroprotective strategies to date for use in acute ischaemic stroke.
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Drugs that act on the platelet P2Y12 receptor are responsible for postoperative bleeding in cardiac surgery. However, protease-activated receptor (PAR) that reacts to thrombin stimulation might still be active in patients treated with P2Y12 inhibitors. Preoperative platelet function testing could possibly guide the timing of surgery. We investigated the association between P2Y12 receptor and PAR inhibition and bleeding after cardiac surgery. ⋯ In patients taking P2Y12 receptor inhibitors, residual platelet reactivity to thrombin stimulation limits the risk of severe postoperative bleeding.