Anaesthesia and intensive care
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Anaesth Intensive Care · Apr 2007
ReviewUpdate in computer-driven weaning from mechanical ventilation.
Weaning from mechanical ventilation is a complex process requiring assessment and interpretation of both objective and subjective clinical parameters. For many years, automated computerised systems for various medical processes, including respiratory management, have been proposed to optimise decision-making and reduce variation amongst clinicians. SmartCare/PS, available since 2003 as a software application for the EvitaXL ventilator (Dräger Medical AG & Co. ⋯ Of potential clinical note, a recent study suggested that use of SmartCare/PS might be associated with useful reductions in the duration of weaning compared to existing clinical practice using weaning protocols. One recently published randomised trial supports this conclusion. However, given the known large variation in international critical care ventilatory practices further randomised trials are desirable.
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Anaesth Intensive Care · Apr 2007
Randomized Controlled TrialThe use of ketamine as rescue analgesia in the recovery room following morphine administration--a double-blind randomised controlled trial in postoperative patients.
In some patients, control of postoperative pain can be difficult with morphine alone. This double-blind randomised controlled trial was designed to evaluate whether a small bolus dose of ketamine could improve pain scores in those patients who had inadequate relief of their postoperative pain after two standard doses of morphine. Forty-one patients with uncontrolled postoperative pain were randomly assigned to receive either morphine (M) alone, or morphine plus 0.25 mg/kg ketamine (K) in the recovery room. ⋯ There was no statistically significant difference in verbal rating scale pain scores between the two groups either in the recovery room (K = 5.16, M = 6.28, P = 0.065), or at a later time on the ward. There was no apparent difference between groups in sedation, morphine consumption, postoperative nausea and vomiting, quality of recovery or need for rescue analgesia. We could not demonstrate an effective role for ketamine in the management of problematic postoperative pain at the dose studied.
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Anaesth Intensive Care · Apr 2007
Comparative StudyA comparison of the degree of residual mitral regurgitation by intraoperative transoesophageal and follow-up transthoracic echocardiography following mitral valvuloplasty.
Patients who undergo mitral valve repair for mitral regurgitation and have mild residual mitral regurgitation may have an increased risk of re-operation in future years. Intraoperative transoesophageal echocardiography has now become a standard of practice for mitral valve repair surgery. We identified 106 patients who underwent attempted mitral valve repair over a three-year period in our institution. ⋯ Mild residual mitral regurgitation on intraoperative transoesophageal echocardiography was not reliably associated with mild mitral regurgitation on follow-up transthoracic echocardiography. In fact, 61% of patients with mild mitral regurgitation identified by intraoperative transoesophageal echocardiography had reduced mitral regurgitation at follow-up transthoracic echocardiography (to nil/trace residual mitral regurgitation). This observation, in conjunction with the limitations of the data supporting the goal of 'echo perfect' repair; suggests that a second attempt at repair should not be made based on the intraoperative transoesophageal echocardiography finding of mild residual mitral regurgitation alone.
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Anaesth Intensive Care · Apr 2007
Comparative StudyChanging from epidural to multimodal analgesia for colorectal laparotomy: an audit.
In April 2002 our practice ceased routine use of epidural analgesia for colorectal laparotomy in favour of a six-drug multimodal regimen comprising ketamine, clonidine, morphine, tramadol, paracetamol and a non-steroidal anti-inflammatory drug. The records of 54 patients who received this multimodal analgesia regimen (MM) after April 2002 were compared to the 59 patients who had previously received epidural analgesia (EPI). Patients had the same surgeon and anaesthetist. ⋯ MM patients had shorter anaesthetic preparation time (20 +/- 8 min vs. 32 +/- 8 min, P < 0.001), shorter high-dependency unit stay (0.4 +/- 1.2 days vs. 4.5 +/- 0.9 days, P < 0.001), and shorter hospital stay (10 +/- 4 days vs. 13 +/- 8 days, P = 0.003). In our practice, changing from epidural to multimodal analgesia produced comparable pain relief with reduction in anaesthesia preparation time, high-dependency unit stay and hospital stay and the requirement for staff interventions. There was also a reduction in the incidence of major complications and side-effects.
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Anaesth Intensive Care · Apr 2007
The proseal laryngeal mask airway in prone patients: a retrospective audit of 245 patients.
The use of the classic laryngeal mask airway (classic LMA) in the prone position is controversial, but the ProSeal laryngeal mask airway (ProSeal LMA) may be more suitable as it forms a better seal and provides access to the stomach. In the following retrospective audit, we describe our experience with the insertion of and maintenance of anaesthesia with, the ProSeal LMA in 245 healthy adults in the prone position by experienced users. The technique involved (1) the patient adopting the prone position with the head to the side and the table tilted laterally; (2) pre-oxygenation to end-tidal oxygen >90%; (3) induction of anaesthesia with midazolam/alfentanil/propofol; (4) facemask ventilation (5) a single attempt at digital insertion and if unsuccessful a single attempt at laryngoscope-guided, gum elastic bougie-guided insertion; (6) gastric tube insertion; (7) maintenance of anaesthesia with sevoflurane/O/N2O; (8) volume controlled ventilation at 8-12 ml/kg; (9) emergence from anaesthesia in the supine position; and (10) removal ofthe ProSeal LMA when awake. ⋯ Gastric tube insertion was successful in all patients. Correctable partial airway obstruction occurred in three patients, but there was no hypoxia, hypercapnoea, displacement, regurgitation, gastric insufflation or airway reflex activation. Our findings suggest that the insertion of and maintenance of anaesthesia with the ProSeal LMA is feasible in the prone position by experienced users.