Anaesthesia
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Randomized Controlled Trial
Effects of ropivacaine concentration on the spread of sensory block produced by continuous thoracic paravertebral block: a prospective, randomised, controlled, double-blind study.
Factors affecting the distribution of continuous thoracic paravertebral block have never been examined. We designed this prospective, double-blind study to check whether continuous thoracic paravertebral block with a higher ropivacaine concentration would provide a wider segmental sensory block spread. Sixty consecutive patients undergoing pulmonary lobectomy or segmentectomy were randomly allocated to receive continuous paravertebral infusion of either 0.2% or 0.5% ropivacaine (6 ml.h(-1) ). ⋯ Twenty-seven patients per group were included in the final analysis. The median (IQR [range]) number of anaesthetised dermatomes 24 h after surgery was 4 (3-6 [1-9]) with ropivacaine 0.2% and 4 (3-6 [2-11]) with ropivacaine 0.5% (p = 0.66). Contrary to our expectation, the segmental spread of sensory block produced by continuous thoracic paravertebral block does not depend on ropivacaine concentration.
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Randomized Controlled Trial
The traffic light bougie: a study of a novel safety modification.
Use of a bougie is not without risk, and insertion too far may cause airway injury. We designed a new bougie with a 'traffic light' system to indicate depth of insertion. Forty anaesthetists were randomly assigned to insert either a conventional single-coloured bougie or a novel traffic light bougie. ⋯ Median (IQR [range]) insertion depth after railroading for the traffic light bougie was 25 (25-28 [21-34]) cm and for the conventional bougie was 30.5 (27-35 [23-40]) cm (p = 0.003). This simple colouring system appears to allow intuitive use and significantly reduced the depth of bougie insertion. This system could be also used with other airway exchange devices to improve safety.
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Observational Study
HIV, vascular surgery and cardiovascular outcomes: a South African cohort study.
Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. ⋯ HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p = 0.78); three-day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.
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Mortality after lower limb amputation is high, with UK 30-day mortality rates of 9-17%. We performed a retrospective analysis of factors affecting early and late outcome after lower limb amputation for peripheral vascular disease or diabetic complications at a UK tertiary referral vascular centre between 2003 and 2010. Three hundred and thirty-nine patients (233 male), of median (IQR [range]) age 73 (62-79 [26-92]) years underwent amputation. ⋯ Anaesthetic technique was associated with long-term mortality on survival analysis (p = 0.04), but not when analysed using regression modelling. Mortality after lower limb amputation relates to patient age, ASA, out-of-hours surgery and renal dysfunction. These data support lower limb amputations' being performed during daytime hours and after modification replace with 'of ' correctable risk factors.
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Observational Study
Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset.
Large observational studies of accurate data can provide similar results to more arduous and expensive randomised controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include 'type of anaesthesia' data fields. We analysed 65 535 patient record sets to determine differences in outcome. ⋯ Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in 30-day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between general and spinal anaesthesia. These could include more anaesthesia-sensitive outcomes, such as hypotension, pain, postoperative confusion, respiratory infection and mobilisation.