Anaesthesia
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Editorial Comment
Through a glass darkly - ultrasound imaging in obstetric anaesthesia.
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Recognising frailty during pre-operative assessment is important. Frail patients experience higher mortality rates and are less likely to return to baseline functional status following the physiological insult of surgery. We evaluated the association between an initial clinical impression of frailty and all-cause mortality in 392 patients attending our vascular pre-operative assessment clinic. ⋯ Using Cox regression, adjusted for age, sex, revised cardiac risk index and surgery (yes/no), the hazard ratio for mortality for frail vs. not-frail was 2.14 (95% CI 1.51-3.05). The time to 20% mortality was 16 months in the frail group and 33 months in the not-frail group. The initial clinical impression is a useful screening tool to identify frail patients in pre-operative assessment.
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Observational Study
Alterations in coagulation following major liver resection.
The international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. ⋯ Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro- and anticoagulant factors suggested a prothrombotic environment in the early postoperative period.
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Randomized Controlled Trial
The minimum effective concentration (MEC90 ) of ropivacaine for ultrasound-guided supraclavicular brachial plexus block.
The aim of this study was to determine the minimum effective concentration of ropivacaine for ultrasound-guided supraclavicular brachial plexus block. Fifty-one patients undergoing arm surgery received double-injection ultrasound-guided supraclavicular block using ropivacaine 40 ml. The concentration of ropivacaine administered to each patient started at 0.225% and then depended on the response of the previous one, based on a biased coin design up-and-down sequential method. ⋯ In the case of a successful block, the next patient was randomised to the same concentration or a concentration 0.025% w/v less. Success was defined as complete sensory blockade of the brachial plexus 30 min after the block together with pain-free surgery. The minimum effective ropivacaine concentration in 90% of subjects was 0.257% w/v (95% CI 0.241-0.280%).