Anaesthesia
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Randomized Controlled Trial
The effect of needle tip tracking on procedural time of ultrasound-guided lumbar plexus block: a randomised controlled trial.
Technology that facilitates performance of deep peripheral nerve blocks is of clinical interest. The Onvision™ is a new device for ultrasonographic needle tip tracking that incorporates an ultrasound sensor on the needle tip that is then represented by a green circle on the ultrasound screen. The primary aim of this study was to investigate the effect of needle tip tracking on procedural time in the first human volunteer study. ⋯ No differences were found for any other secondary outcomes. The use of Onvision needle tip tracking did not reduce procedural time for out-of-plane ultrasound-guided lumbar plexus block but did reduce the number of hand movements and path lengths. This may indicate improved needle control but further studies are needed to confirm this finding.
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Traditional surgical outcome measures include minor and major complications, hospital length of stay and sometimes longer-term survival. Each of these is important but there needs to be greater emphasis on patient-reported outcome measures. ⋯ A patient's recovery pathway can be mapped through the immediate days or weeks after surgery with documentation of morbidity using the postoperative morbidity survey and/or a quality of recovery score, days alive and at home up to 30 days after surgery and then longer term disability-free survival using the WHO Disability Assessment Schedule 2.0 scale. These can be used to define quality of recovery after surgery.
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Observational Study
Impact of loop diuretics on critically ill patients with a positive fluid balance.
The impact of the use of loop diuretics to prevent cumulative fluid balance in non-oliguric patients is uncertain. This is a retrospective study to estimate the association of time-averaging loop diuretic exposure in a large population of non-cardiac, critically ill patients with a positive fluid balance (> 5% of body weight). The exposure was loop diuretic and the main outcomes were 28-day mortality, severe acute kidney injury and successful mechanical ventilation weaning. ⋯ The main results were consistent in the sub-group analysis for sepsis, oliguria and the study period (2002-2007 vs. 2008-2012). Also, equivalent doses of up to 80 mg per day of furosemide had no significant association with mortality. After adjusting for time-varying variables, the time average of loop diuretic exposure in non-cardiac, critically ill patients has no association with overall mortality or severe acute kidney injury; however, prolonged mechanical ventilation is a concern.
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Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri-operative research agenda to ensure co-ordinated, collaborative research efforts across Africa in order to decrease peri-operative mortality. ⋯ The top 10 research priorities identified were (1) Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence-based practice guidelines for peri-operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri-operative outcomes associated with emergency surgery. These peri-operative research priorities provide the structure for an intermediate-term research agenda to improve peri-operative outcomes across Africa.
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Review
Critical care after major surgery: a systematic review of risk factors for unplanned admission.
Critical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri-operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30-day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. ⋯ Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.