Anaesthesia
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Review Meta Analysis
A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks.
Perineural dexamethasone may significantly increase the duration of analgesia after regional blockade, though without dose-response effect.
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There has been an explosion of interest in the ability of tranexamic acid to reduce morbidity and mortality in surgical and traumatic bleeding. Tranexamic acid has been shown to reduce mortality due to traumatic bleeding by a third, without apparent safety issues. It is now clearly established that intravenous tranexamic acid reduces blood loss in patients with surgical bleeding and the need for transfusion. ⋯ However, clinical studies suggest that there is no increased efficacy in using a higher dose, and that a dose of 1 g intravenously in an adult patient has maximal efficacy, which is not increased by higher doses. The CRASH-2 trauma trial clearly showed no increase in thrombotic events after its use in trauma, indeed there was a significant reduction in myocardial infarction. However, trials of tranexamic acid in surgery have failed to adequately study its effects on the risk of postoperative venous and possible reduction in arterial thrombo-embolism, and this needs to be the subject of future research.
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Peri-operative coagulation monitoring should begin with the assessment of individual bleeding risk using a standardised bleeding history before the surgical procedure. Laboratory testing should be performed if this history is abnormal or peri-operative bleeding is anticipated. ⋯ In bleeding patients, routine coagulation tests should be requested, but one should be aware of the major limitations that exist. Delay whilst waiting for these laboratory results, which, in turn, aggravates coagulopathy, bleeding, blood product requirements, length of surgery and overall morbidity and mortality.
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As compared with European practice, the American approach to resuscitation from traumatic haemorrhage de-emphasises pre-hospital interventions in favour of rapid transport to definitive care; limits initial surgical interventions under the damage control model; uses crystalloid as the initial fluid of choice; and follows an empiric 1:1:1 approach to transfusion with red cells, plasma and platelets in hemodynamically unstable and actively bleeding patients. The use of bedside visco-elastic testing to guide coagulation support is not as widespread as in Europe, while the early administration of tranexamic acid is more selective.
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There is both medical and political drive to centralise secondary services in larger hospitals throughout the National Health Service. High-volume services in some areas of care have been shown to achieve better outcomes and efficiencies arising from economies of scale. ⋯ The intention is that the model should be generic and transferable for those looking to merge and rationalise services on to one site. One of the advantages of mathematical modelling is the ability to interrogate the model to investigate any number of different scenarios; some of these are presented.