Anaesthesia
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We systematically reviewed 25 randomised controlled trials of ultrasound-guided brachial plexus blockade that recruited 1948 participants: either one approach vs another (axillary, infraclavicular or supraclavicular); or one injection vs multiple injections. There were no differences in the rates of successful blockade with approach, relative risk (95% CI): axillary vs infraclavicular, 1.0 (1.0-1.1), p = 0.97; axillary vs supraclavicular, 1.0 (1.0-1.1), p = 0.68; and infraclavicular vs supraclavicular, 1.0 (1.0-1.1), p = 0.32. There was no difference in the rate of successful blockade with the number of injections, relative risk (95% CI) 1.0 (1.0-1.0), p = 0.69, for one vs multiple injections. The rate of procedural paraesthesia was less with one injection than multiple injections, relative risk (95% CI) 0.6 (0.4-0.9), p = 0.004.
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There is little doubt that these guidelines incorporate advances made in airway management since 2004. They will change day-to-day practice of anaesthesia, as outlined above, from pre-operative airway assessment, to integrating the WHO team briefing, to the use and provision of equipment and drugs, and the recording of information on the anaesthesia chart. They will inform the later analysis of any critical airway incidents, especially as documentation and postoperative management are addressed, and they will encourage training in a range of techniques. ⋯ Formal testing may reveal which aspects of their design, complex as it is, may distract from, rather than enhance, airway management during crises. All guidelines represent a standard of care or a normative approach to a clinical problem. As such, they not only help guide clinicians, but they also provide the broader community with the opportunity to improve standards, to ensure equipment is available, and that training for the skills and processes required are in place to ensure successful adoption.
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Randomized Controlled Trial
A randomised controlled trial of peri-operative pregabalin vs. placebo for video-assisted thoracoscopic surgery.
We allocated 52 participants to oral pregabalin 300 mg and 48 participants to placebo tablets before thoracoscopic surgery and for five postoperative days. The median (IQR [range]) cumulative pain scores at rest for nine postoperative months were 184 (94-274 [51-1454]) after pregabalin and 166 (66-266 [48-1628]) after placebo, p = 0.39. ⋯ After three postoperative months, 29/100 participants had persistent surgical site pain, 19/52 after pregabalin and 10/48 after placebo, p = 0.12, of whom four and five, respectively, attended a pain management clinic, p = 0.24. The median (IQR [range]) morphine equivalent consumption six days after surgery was 273 (128-619 [39-2243]) mg after pregabalin and 319 (190-663 [47-2258]) mg after placebo, p = 0.35.
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Isotonic saline is a widely-used infusion fluid, although the associated chloride load may cause metabolic acidosis and impair kidney function in young, healthy volunteers. We wished to examine whether these effects also occurred in the elderly, and conducted a crossover study in 13 men with a mean age of 73 years (range 66-84), who each received intravenous infusions of 1.5 l of Ringer's acetate and of isotonic saline. ⋯ The glomerular filtration rate increased in response to both fluids, but more after the Ringer's acetate (p < 0.03). Pre-infusion fluid retention, as evidenced by high urinary osmolality (> 700 mOsmol.kg(-1) ) and/or creatinine (> 7 mmol.l(-1) ), was a strong factor governing the responses to both fluid loads.
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A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric(®) , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. ⋯ The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.