Anaesthesia and intensive care
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We undertook a systematic review to determine the optimal dose of oxytocin after elective caesarean section or caesarean section in labouring women. We identified seven trials. These trials raise questions about the use of high dose (10 international units; IU) or moderate dose (5 IU) oxytocin in both settings and provide evidence that lower doses are equally effective but associated with significantly fewer side-effects. ⋯ For the labouring parturient a slow 3 IU bolus of oxytocin, followed by an infusion of 5 to 10 IU.h(-1) for four hours is supported by limited evidence. These doses represent a starting point in the control of postpartum haemorrhage after caesarean section and do not reduce the need for mandatory active observation of the clinical situation, to detect situations that require additional doses of oxytocin or other uterotonic drugs. These doses of oxytocin minimise the risk of adverse haemodynamic changes as well as the unpleasant side-effect of nausea.
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Anaesth Intensive Care · Mar 2012
ReviewRespiratory dysfunction in ventilated patients: can inspiratory muscle training help?
Respiratory muscle dysfunction is associated with prolonged and difficult weaning from mechanical ventilation. This dysfunction in ventilator-dependent patients is multifactorial: there is evidence that inspiratory muscle weakness is partially explained by disuse atrophy secondary to ventilation, and positive end-expiratory pressure can further reduce muscle strength by negatively shifting the length-tension curve of the diaphragm. Polyneuropathy is also likely to contribute to apparent muscle weakness in critically ill patients, and nutritional and pharmaceutical effects may further compound muscle weakness. ⋯ There is recent evidence that inspiratory muscle training is safe and feasible in selected ventilator-dependent patients, and that this training can reduce the weaning period and improve overall weaning success rates. Extrapolating from evidence in sports medicine, as well as the known effects of inspiratory muscle training in chronic lung disease, a theoretical model is proposed to describe how inspiratory muscle training enhances weaning and recovery from mechanical ventilation. Possible mechanisms include increased protein synthesis (both Type 1 and Type 2 muscle fibres), enhanced limb perfusion via dampening of a sympathetically-mediated metaboreflex, reduced lactate levels and modulation of the perception of exertion, resulting in less dyspnoea and enhanced exercise capacity.