British journal of anaesthesia
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Perioperative neuronal injury includes both delirium and postoperative cognitive decline, and has profound potentially long-term effects on surgical patients and an economic cost. Recent advances have been made in the underlying biological causes of these injuries, including validation of biomarkers of neuronal damage such as neurofilament light, further understanding of the inflammatory pathways and mediators responsible for neuronal injuries, metabolic triggers, and the role of ischaemia. Several novel approaches to perioperative protection of brain health are also being trialled. We summarise the current evidence regarding the causes of neuronal injury, and work taking place related to its prevention and treatment.
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Neuromuscular blocking agents are a common cause of perioperative hypersensitivity. The sensitivity and specificity of skin tests and in vitro tests in this context have not been determined conclusively, which poses a barrier to accurate diagnosis. ⋯ However, its use is currently limited to specialised centres, and a standardised approach to testing has not yet been established. This article summarises the role of challenge testing to neuromuscular blocking agents and highlights the advantages and disadvantages of the different approaches.
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Despite the numerous recent trials, systematic reviews and meta-analyses have not conclusively shown superiority of videolaryngoscopy over other techniques for tracheal intubation of children. Clinical trials have shown significant differences using various outcome measures, but the overall clinical evidence remains weak. An international group of experts is currently working on developing good clinical research practice guidelines for paediatric airway management research, with the ultimate aim of identifying a core set of outcomes to be applied to develop future robust and comparable trials.
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Editorial Review
Postoperative respiratory complications in children: from prediction to clinical action.
The score for prediction of postoperative respiratory complications in infants and children (SPORC-C) was recently reported. The score was developed using a large cohort of patients by applying a multivariate model, then internally and externally validated on a different cohort of patients. In order to encourage use of this score, an online calculator (https://sites.google.com/view/sporc-for-children/home) was also developed, allowing identification of patients at low and high risk for postoperative respiratory complications. We review current evidence on algorithms developed to predict postoperative respiratory complications, including how and when such scoring systems should be used in daily practice to improve the overall safety of paediatric patients.
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Etomidate, an intravenous hypnotic used for anaesthesia and critical care, is known for its undesirable side effects, including pain on injection, myoclonus, and adrenocortical depression. Despite its continued clinical use because of its haemodynamic stability and rapid onset and offset of effect, alternatives like propofol, ketamine, and remimazolam offer fewer drawbacks. Recent efforts to improve etomidate through chemical modifications, such as methoxyethyl etomidate hydrochloride (ET-26), have shown limited success, with persistent issues like involuntary muscle movements and adrenocortical suppression. We suggest that it might be time to move on from etomidate and focus on developing new anaesthetic agents.