Anaesthesia
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Randomized Controlled Trial Comparative Study Clinical Trial
Transoesophageal echocardiography is unreliable for cardiac output assessment after cardiac surgery compared with thermodilution.
This randomised, single-blind, double-control study compared and established prospectively the best transoesophageal echocardiography methods for determining cardiac output in patients after cardiac surgery. Thirty patients undergoing coronary artery bypass grafting were included. Measurements were taken postoperatively, after stabilisation in the intensive care unit. ⋯ The best results were transaortic measurements using the triangular shape assumption of valve opening, but some values deviated considerably, and none of these approaches reached the limit of agreement set at 30% when compared to thermodilution. Eyeball guessing was comparable to the best transoesophageal echocardiography measurements. We conclude that transoesophageal echocardiography is an unreliable tool for determination of cardiac output in intensive care after cardiac surgery.
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A 45-year-old alcoholic man presented following several short grand-mal seizures. He was not known to be epileptic. ⋯ The patient recovered within 4 h of management with oxygen, fluids and sodium bicarbonate. Lactic acidosis following convulsions is often associated with spontaneous resolution and a favourable outcome.
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Of the forms of muscular dystrophy, myotonic dystrophy has the greatest systemic involvement. Although most patients with myotonic dystrophy show normal sensitivity to non-depolarising neuromuscular blocking drugs, some have been reported to show greatly increased sensitivity to these drugs, and little is known about the sensitivity of different muscles. ⋯ The calculated ED50 for the orbicularis oculi (7.77 microg x kg(-1) (95% CI 3.10-16.8 microg x kg(-1))) was lower than for the adductor pollicis (25.3 microg x kg(-1) (95% CI 20.7-43.3 microg x kg(-1))) and flexor hallucis brevis muscles (29.5 microg x kg(-1) (95% CI 11.0-85.6 microg x kg(-1); p < 0.01)). The ED90 was also lower for the orbicularis oculi (35.7 microg x kg(-1) (95% CI 14.8-66.5 microg x kg(-1))) than for the other muscles (51.8 microg x kg(-1) (95% CI 29.3-145.0 microg x kg(-1)) and 50.6 microg x kg(-1) (95% CI 5.29-642.0 microg x kg(-1)), respectively) (p < 0.01)).
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Case Reports
Use of alpha-agonists for management of anaphylaxis occurring under anaesthesia: case studies and review.
Anaphylaxis is an uncommon but serious complication of anaesthesia. Most current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of cardiovascular collapse. We present two cases of anaphylaxis under anaesthesia where return of spontaneous circulation was refractory to epinephrine, but occurred following the administration of the alpha-agonist metaraminol. Potential advantages and disadvantages of using epinephrine in this setting, the role of alpha-agonists and some potential mechanisms accounting for their role in successful management are reviewed.
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The history of the design of spinal needle tips is discussed, from the first needles used by J. Leonard Corning in 1885 to innovative, modern needle designs that continue to appear on the market. The shape of the needle tip started as a cutting bevel and developed into the atraumatic tip and the pencil-point tip in current common use. Innovative designs such as the stylet-tipped needle and the directional needle are described, as well as the needles used for continuous spinal anaesthesia.