British journal of anaesthesia
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Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. ⋯ Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.
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Review
Vascular surgery-related organ injury and protective strategies: update and future prospects.
Whilst there has been a reduction in the prevalence of peripheral vascular disease worldwide, a significant proportion of the world's growing population is still affected by disease of the aorta, carotid, iliac and lower limb arteries. These if left untreated can result in severe morbidity and mortality. However vascular surgery, the main definitive treatment for such conditions, is associated with subsequent injury to vital organs including the kidneys, heart, brain, intestines and lungs, with a consequent increase in both morbidity and mortality. ⋯ Various methods to alleviate such injuries have been investigated including pre- and postconditioning strategies, pharmacological therapies including volatile anaesthetic and alpha2 adrenoceptor agonist drugs and more recently remote conditioning strategies. Although these interventions have demonstrated some reduction in the biomarkers for organ injury, attempts to translate these benefits into clinical practice have not been successful in terms of morbidity, mortality or length of hospital stay. For this reason, further research is needed in this area to facilitate the translation of the potential interventional benefits from bench to bedside.
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Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. ⋯ The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.
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Review Meta Analysis
Thoracic paravertebral blocks in abdominal surgery - a systematic review of randomized controlled trials.
Thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multimodal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery. We performed a systematic review of randomized controlled trials, to clarify the impact of TPVB on perioperative analgesic outcomes in adult abdominal surgery. ⋯ The reported primary block failure rate was 2.8% and the incidence of complications was 1.2% (6/504); there were no instances of pneumothorax. TPVB therefore appears to be a promising analgesic technique for abdominal surgery in terms of efficacy and safety. But further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anaesthesia techniques.
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Review Meta Analysis
Thoracic paravertebral blocks in abdominal surgery - a systematic review of randomized controlled trials.
Thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multimodal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery. We performed a systematic review of randomized controlled trials, to clarify the impact of TPVB on perioperative analgesic outcomes in adult abdominal surgery. ⋯ The reported primary block failure rate was 2.8% and the incidence of complications was 1.2% (6/504); there were no instances of pneumothorax. TPVB therefore appears to be a promising analgesic technique for abdominal surgery in terms of efficacy and safety. But further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anaesthesia techniques.