Anaesthesia
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Review Comparative Study
Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review.
We aimed to assess the effectiveness of remifentanil used as intravenous patient-controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster-randomised trials of women in labour with planned vaginal delivery receiving patient-controlled remifentanil compared principally with other parenteral and patient-controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. ⋯ However, the relative risk (95%CI) for maternal respiratory depression for patient-controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low-quality evidence) was 0.91 (0.51-1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low-quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low-quality evidence) was 1.26 (0.62-2.57).
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Multicenter Study
Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database.
Hip fracture is the most common reason for older patients to need emergency anaesthesia and surgery. Up to one-third of patients die in the year after hip fracture, but this view of outcome may encourage therapeutic nihilism in peri-operative decisions and discussions. We used a multicentre national dataset to examine relative and absolute mortality rates for patients presenting with hip fracture, stratified by ASA physical status. ⋯ Nearly half (48.6%) of the 1427 patients who did not have surgery died in hospital. Although technically sound, a focus on cumulative and relative risk of mortality may frame discussions in an unduly negative fashion, discouraging surgeons and anaesthetists from offering an operation, and deterring patients and their loved ones from agreeing to it. A more optimistic and pragmatic explanation that over 98% of ASA 4 patients survive both the day of surgery and the day after it, may be more appropriate.
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Randomized Controlled Trial
A randomised, controlled trial evaluating a low cost, 3D-printed bronchoscopy simulator.
Low-fidelity, simulation-based psychomotor skills training is a valuable first step in the educational approach to mastering complex procedural skills. We developed a cost-effective bronchial tree simulator based on a human thorax computed tomography scan using rapid-prototyping (3D-print) technology. This randomised, single-blind study evaluated how realistic our 3D-printed simulator would mimic human anatomy compared with commercially available bronchial tree simulators (Laerdal® Airway Management Trainer with Bronchial Tree and AirSim Advance Bronchi, Stavanger, Norway). ⋯ The 3D-printed simulator was rated most realistic for the localisation of the right upper lobe bronchial lumen (p = 0.002), but no differences were found in placement of a bronchial blocker or for aspiration of fluid (p = 0.792 and p = 0.057) compared with using the commercially available simulators. Overall, the 3D-printed simulator was rated most realistic (p = 0.021). Given the substantially lower costs for the 3D-printed simulator (£85 (€100/US$110) compared with > ~ £2000 (€2350/US$2590) for the commercially available simulators), our 3D-printed simulator provides an inexpensive alternative for learning bronchoscopy skills, and offers the possibility of practising procedures on patient-specific models before attempting them in clinical practice.