Anaesthesia
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Accurate assessment of intravascular fluid status and measurement of fluid responsiveness have become increasingly important in peri-operative medicine and critical care. The objectives of this systematic review and narrative synthesis were to discuss current controversies surrounding fluid responsiveness and describe the merits and limitations of the major cardiac output monitors in clinical use today in terms of usefulness in measuring fluid responsiveness. We searched the MEDLINE and EMBASE databases (2002-2015); inclusion criteria included comparison with an established reference standard such as pulmonary artery catheter, transthoracic echocardiography and transoesophageal echocardiography. ⋯ Due to heterogeneity of the methods and patient characteristics, we did not perform a meta-analysis. In most studies, precision and limits of agreement (bias ±1.96SD) between determinants of fluid responsiveness measured by different devices were not evaluated, and the definition of fluid responsiveness varied across studies. Future research should focus on the physiological principles that underlie the measurement of fluid responsiveness and the effect of different volume expansion strategies on outcomes.
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Cardiovascular complications are an important cause of morbidity and mortality after non-cardiac surgery. Pre-operative identification of high-risk individuals and appropriate peri-operative management can reduce cardiovascular risk. It is important to continue chronic beta-blocker and statin therapy. ⋯ Aspirin continuation can increase the risk of major bleeding and offset the benefit of reduced myocardial risk. Contrary to the initial ENIGMA study, nitrous oxide does not seem to increase the risk of myocardial injury. Volatile anaesthetic agents and opioids have been shown to be cardioprotective in animal laboratory studies but these effects have, so far, not been conclusively reproduced clinically.
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Randomized Controlled Trial Comparative Study
Nasotracheal intubation in patients with limited mouth opening: a comparison between fibreoptic intubation and the Trachway(®).
In patients with limited mouth opening, traditional laryngoscopy and videolaryngoscopes are not useful when performing nasotracheal intubation. Eighty patients with limited mouth opening who required nasotracheal intubation were randomly assigned to either fibreoptic intubation (n = 40) or the Trachway(®) (n = 40). ⋯ Mean (SD) total intubation time was 71.8 (23.3) s in patients who received fibreoptic intubation compared with 35.4 (9.8) s in the Trachway group (p < 0.001). We conclude that the Trachway technique for nasotracheal intubation is quicker and easier compared with fibreoptic intubation in patients with limited mouth opening.
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Pulmonary complications are a major cause of peri-operative morbidity and mortality, but have been researched less thoroughly than cardiac complications. It is important to try and predict which patients are at risk of peri-operative pulmonary complications and to intervene to reduce this risk. Anaesthetists are in a unique position to do this during the whole peri-operative period. Pre-operative training, smoking cessation and lung ventilation with tidal volumes of 6-8 ml.kg(-1) and low positive end-expiratory pressure probably reduce postoperative pulmonary complications.
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Randomized Controlled Trial Comparative Study
A comparison of single dose dexmedetomidine with propofol for the prevention of emergence delirium after desflurane anaesthesia in children.
Emergence delirium is a common problem in children recovering from general anaesthesia. We performed a study comparing emergence characteristics in 100 patients who were randomly allocated to receive either 0.3 μg.kg(-1) dexmedetomidine, 1 mg.kg(-1) propofol or saline 0.9% and undergoing infra-umbilical surgery. ⋯ In the dexmedetomidine group, sedation occurred in 62.5% of children at 10 min after transfer to the recovery area, compared with 44.4% in the propofol group and 12.5% in the control group (p = 0.010). We conclude that dexmedetomidine significantly reduced the incidence of emergence delirium but this was at the expense of a greater incidence of sedation in the recovery period.