Anaesthesia
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Randomized Controlled Trial Clinical Trial
Fenoldopam: renal and splanchnic effects in patients undergoing coronary artery bypass grafting.
Impairment of renal and splanchnic perfusion during and after cardiopulmonary bypass may be responsible for acute renal failure and endotoxin-mediated systemic inflammation, respectively. We hypothesised that fenoldopam, a selective dopamine receptor agonist, would preserve renal function after cardiopulmonary bypass through its selective renal vasodilatory and natriuretic effects, and increase gastrointestinal mucosal perfusion by selective splanchnic vasodilation. We examined the effects of fenoldopam on haemodynamic parameters, creatinine clearance, fractional excretion of sodium, urine output, free water clearance and gastric mucosal pH in 31 patients undergoing elective coronary revascularisation. ⋯ In the placebo group, but not the fenoldopam group, mean (SD) creatinine clearance decreased after separation from cardiopulmonary bypass, from 107 (36) to 71 (22) ml x min(-1) (p < 0.01) and from 107 (36) to 79 (26) ml x min(-1) (p < 0.01) for the 0-4 h and 4-8 h intervals after cardiopulmonary bypass, respectively. Changes in intramucosal pH were similar in both groups. The findings are consistent with the hypothesis that fenoldopam possesses a renoprotective effect in patients undergoing cardiopulmonary bypass.
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By enhancing gaseous uptake from the non-ventilated lung during procedures performed thoracoscopically, the rapid diffusion properties of nitrous oxide would be expected to speed lung collapse and so facilitate surgery. To assess the effect of nitrous oxide on the speed of absorptive lung collapse, a study was conducted using 11 anaesthetised sheep. ⋯ In all assessments, it was found that the decrease in airway pressure to - 1.0 kPa occurred in a shorter time when nitrous oxide was used. The findings lend support to the hypothesis that during thoracoscopic surgery, mechanical lung ventilation with an oxygen/nitrous oxide mixture will increase the rate of gaseous uptake from the non-ventilated lung and so hasten its absorptive collapse.
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Pre-operative optimisation of high-risk patients undergoing major elective surgery has been shown to decrease peri-operative morbidity and mortality. It is also cost effective because of the resulting decrease in postoperative complications. A questionnaire was sent to 170 intensive care and high dependency units in Britain in order to quantify the number of units practising pre-operative optimisation. ⋯ Moreover, only eight units (6%) admit more than 25% of eligible patients. The reasons given for not admitting such patients pre-operatively are a lack of manpower, beds or both. This survey demonstrates the need for greater investment of resources into intensive care and high dependency units, so that clinicians can deliver high-quality evidence-based healthcare in accordance with the principles of clinical governance.
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Comment Letter Case Reports
Systemic spread of vecuronium following use in peribulbar regional anaesthesia.