Anaesthesia
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Review Comparative Study
A performance comparison of the paediatric i-gel(™) with other supraglottic airway devices.
We performed a review of published literature comparing the i-gel with other supraglottic airway devices in children. Sixty-two articles were identified following a literature search; we included data from 14 randomised controlled trials and eight observational studies that compared i-gel sizes 1-2.5 with other commonly used, equivalently-sized, devices. The primary outcome in most studies was oropharyngeal leak pressure. ⋯ Insertion success rate, gastric tube placement and complications were similar for all the devices. Seven of the eight observational studies measured average oropharyngeal leak pressures of 20-27 cmH2O and all had first-time insertion success rates exceeding 90%. We conclude that the i-gel is at least equivalent to other supraglottic airway devices currently available for use in children, and may enable a higher oropharyngeal leak pressure and an improved fibreoptic view of the glottis.
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The management of antithrombotic therapy in the peri-operative setting is a common problem, balancing haemorrhagic risk with continued treatment and thrombotic risk when discontinued. High-quality evidence is lacking regarding the optimal approach for patients on oral anticoagulants or antiplatelet agents. ⋯ Aspirin can be continued for most procedures. Dual antiplatelet agents for patients with a recently inserted coronary artery stent should be continued if possible but decisions should be individualised and taken after multidisciplinary discussion.
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Allogeneic red cell transfusion is a commonly used treatment to improve the oxygen carrying capacity of blood during the peri-operative period. Increasing arterial oxygen content by increasing haemoglobin does not necessarily increase tissue oxygen delivery or uptake. Although the evidence-base for red cell transfusion practice is incomplete, randomised studies across a range of clinical settings, including surgery, consistently support the restrictive use of red cells, with no evidence of benefit for maintaining patients at higher haemoglobin thresholds (liberal strategy). ⋯ The degree to which the optimal haemoglobin concentration or transfusion trigger should be modified for patients with additional specific risk factors (e.g. ischaemic heart disease), remains less clear and requires further research. Although most clinical practice guidelines recommend restrictive use of red cells, and many blood transfusion services have seen marked falls in overall usage of red cells, the use of other blood components such as fresh frozen plasma, platelets, and cryoprecipitate has risen. In clinical practice, administration of fresh frozen plasma is usually guided by laboratory tests of coagulation, mainly prothrombin time, international normalised ratio and activated partial thromboplastin time, but the predictive value of these tests to predict bleeding is poor.
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Understanding the complex immunological consequences of red cell transfusion is essential if we are to use this valuable resource wisely and safely. The decision to transfuse red cells should be made after serious considerations of the associated risks and benefits. ⋯ Red cell transfusions should be acknowledged as immunological exposures, with consequences weighed against expected benefits. This article reviews immunological consequences and the emerging evidence that may inform risk-benefit considerations in clinical practice.