Created September 28, 2015, last updated about 12 hours ago.
Collection: 60, Score: 997, Trend score: 0, Read count: 998, Articles count: 19, Created: 2015-09-28 06:00:57 UTC. Updated: 2020-09-11 07:59:48 UTC.
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Monitoring neuromuscular blockade with TOF at the eye muscles (orbicularis oculi) results in a 5 times greater risk (adjusted odds ratio) of postoperative residual curarization (PORC) than monitoring at the hand (adductor pollicis) when PORC is defined by TOFR < 90% using acceleromyography.
PORC was nonetheless common in both groups, occurring in 52% and 22% respectively.summary
Randomized Controlled Trial Observational Study
Randomized Controlled Trial Multicenter Study Comparative Study
Unintended intraoperative awareness, which occurs when general anesthesia is not achieved or maintained, affects up to 1% of patients at high risk for this complication. We tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) is superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness. ⋯ The superiority of the BIS protocol was not established; contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness. (Funded by the Foundation for Anesthesia Education and Research and others; BAG-RECALL ClinicalTrials.gov number, NCT00682825.).
An understanding of the half-life (T1/2) of infused fluids can help prevent iatrogenic problems such as volume overload and postoperative interstitial oedema. Simulations show that a prolongation of the T1/2 for crystalloid fluid increases the plasma volume and promotes accumulation of fluid in the interstitial fluid space. The T1/2 for crystalloids is usually 20 to 40 min in conscious humans but might extend to 80 min or longer in the presence of preoperative stress, dehydration, blood loss of <1 l or pregnancy. ⋯ The commonly used colloid fluids have an intravascular persistence T1/2 of 2 to 3 h, which is shortened by inflammation. The fact that the elimination T1/2 of the infused macromolecules is 2 to 6 times longer shows that they also reside outside the bloodstream. With a colloid, fluid volume is eliminated in line with its intravascular persistence, but there is insufficient data to know if this is the same in the clinical setting.
Fluid therapy is considered a cornerstone of perioperative and critical care medicine. However, the type of fluids used varies widely among different countries. Synthetic colloids may negatively affect coagulation and are potentially nephrotoxic. "Modern" hydroxyethyl starches (HES) were widely used until recently when their association to mortality and renal replacement therapy risk among critically ill patients brought to restriction by the European Medicines Agency in 2013. ⋯ The aim of this contribution is to warn clinicians that gelatins share all potential adverse effects of other synthetic colloids, and are possibly even more nephrotoxic than HES. Moreover, gelatins have no beneficial effects on outcomes as compared with crystalloids (on the contrary, they might even increase mortality), and are also more expensive. Accordingly, a "return" to gelatins should be strongly discouraged.
Randomized Controlled Trial Comparative Study
We compared the transverse and longitudinal approaches to ultrasound-guided identification of the cricothyroid membrane, to determine which was faster and more successful. Forty-two anaesthetists received a one-hour structured training programme consisting of e-learning, a lecture and hands-on training, and then applied both techniques in a randomised, cross-over sequence to obese females with body mass index 39.0 - 43.9 kg.m(-2). The mean (SD) time to identify the cricothyroid membrane was 24.0 (12.4) s using the transverse technique compared with 37.6 (17.9) s for the longitudinal technique (p = 0.0003). ⋯ All anaesthetists were successful in identifying the cricothyroid membrane with at least one of the techniques. We advocate the learning and application of these two techniques for identification of the cricothyroid membrane before starting anaesthesia in difficult patients, especially when anatomical landmarks are impalpable. Further use in emergency situations is feasible, if clinicians have experience and the ultrasound machine is readily available.
We included six trials with 2524 participants. Capnography reduced hypoxaemic episodes, relative risk (95% CI) 0.71 (0.56-0.91), p = 0.02, but the quality of evidence was poor due to high risks of performance bias and detection bias and substantial statistical heterogeneity. The reduction in hypoxaemic episodes was statistically homogeneous in the subgroup of three trials of 1823 adults sedated for colonoscopy, relative risk (95% CI) 0.59 (0.48-0.73), p < 0.001, although the risks of performance and detection biases were high. There was no evidence that capnography affected other outcomes, including assisted ventilation, relative risk (95% CI) 0.58 (0.26-1.27), p = 0.17.
We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). ⋯ The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.
Review Meta Analysis
Meta Analysis Comparative Study
Comparing PECARN, CATCH, and CHALICE Rules for Children With Minor Head Injury along with two modalities of physician judgement showed significant variation in the sensitivities and specificities of the five modalities. Only physician practice and PECARN identified all traumatic brain injuries at a cost of lower specificity compared with CHALICE.summary
Fink & Hollman describe and refute several commonly-held myths regarding neuromuscular pharmacology. Their evidence-supported arguments are:
- Intubating patients without muscle relaxants is less safe and sub-optimal.
- Even if you know muscle relaxant pharmacokinetics, it is sufficiently unpredictable that neuromuscular monitoring and reversal is still necessary.
- Post-operative residual curarization (PORC) is clinically significant with real consequences.
- Postoperative residual curarization (PORC) is common.
- Postoperative residual curarisation (PORC) (TOFR < 0.9) can only be diagnosed with a quantitative neuromuscular monitor. Clinical tests are insufficient and poorly sensitive.
Randomized Controlled Trial Multicenter Study
We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy. ⋯ We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m2, we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy.
Obesity is a serious disorder and may bring about many difficulties of perioperative management. A systematic review was conducted to assess the association between obesity and difficult intubation. ⋯ Obesity was associated with an increased risk of difficult intubation, difficult laryngoscopy and Mallampati score ≥ 3 in adults patients undergoing general surgical procedures. However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies and the elective tracheal intubation, no associated with an increased risk of difficult laryngoscopy in the sniffing position. Future analyses should explore the association of BMI and difficult airway.
Previous studies have failed to detect high body mass index (BMI) as a risk factor for difficult tracheal intubation (DTI). BMI was investigated as a risk factor for DTI in patients planned for direct laryngoscopy. ⋯ High BMI is a weak but statistically significant predictor of difficult and failed intubation and may be more appropriate than weight in multivariate models of prediction of DTI.
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