Anaesthesia
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Review Meta Analysis
Peri-articular infiltration analgesia for shoulder surgery: a systematic review and meta-analysis.
Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. ⋯ In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique.
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Organ donation after brain death remains the deceased organ donation pathway of choice. In the UK, the current identification and referral rate for potential donation after brain death donors is 99%, the testing rate for determining death using neurological criteria is 86% and the approach to families for donation is 91%. Increasing donation after brain death donation will primarily require a large increase in the current consent rate of 72% to one matching the consent rate of 80-90% achieved in other European countries. ⋯ Alternatively, the UK will need to look at more challenging ways of increasing the pool of potential donors after brain death. The first would be to delay the withdrawal of life-sustaining treatment in patients with devastating brain injury to allow progression to brain death after the family have given consent to organ donation and with their consent to this delay. Even more challenging would be the consideration of re-introducing intensive care to facilitate organ donation programmes that have been so successful at increasing the number of organ donors elsewhere.
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Historically, there has been a tendency to think that there are two types of death: circulatory and neurological. Holding onto this tendency is making it harder to navigate emerging resuscitative technologies, such as extracorporeal membrane oxygenation and the recent well-publicised experiment that demonstrated the possibility of restoring cellular function to some brain neurons 4 h after normothermic circulatory arrest (decapitation) in pigs. Attempts have been made to respond to these difficulties by proposing a unified brain-based criterion for human death, which we call 'permanent brain arrest'. ⋯ These losses could arise from a primary brain injury or as a result of systemic circulatory arrest. We argue that permanent brain arrest is the true and sole criterion for the death of human beings and show that this is already implicit in the circulatory-respiratory criterion itself. We argue that accepting the concept of permanent cessation of brain function in patients with systemic permanent circulatory arrest will help us better navigate the medical advances and new technologies of the future whilst continuing to provide sound medical criteria for the determination of death.