Anaesthesia
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Comparative Study
A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.
We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. ⋯ Māori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Māori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Māori patients had worse outcomes than non-Māori.
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Randomized Controlled Trial Multicenter Study Comparative Study
Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial.
There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster-randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. ⋯ Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full-scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.
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In 2019, the scientists who discovered how cells sense and adapt to oxygen availability were awarded the Nobel Prize. This elegant sensing pathway is conserved throughout evolution, and it underpins the physiology and pathology that we, as clinicians in anaesthesia and critical care, encounter on a daily basis. ⋯ We explore the lessons learnt from genetic disorders of oxygen sensing, and the wider implications in evolution of all animal species, including our own. Finally, we explain how this pathway is relevant to our clinical practice, and how it is being manipulated in new treatments for conditions such as cancer, anaemia and pulmonary hypertension.
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The association between intra-operative hypotension and postoperative acute kidney injury, mortality and length of stay has not been comprehensively evaluated in a large single-centre hip fracture population. We analysed electronic anaesthesia records of 1063 patients undergoing unilateral hip fracture surgery, collected from 2015 to 2018. Acute kidney injury, 3-, 30- and 365-day mortality and length of stay were evaluated to assess the relationship between intra-operative hypotension absolute values (≤ 55, 60, 65, 70 and 75 mmHg) and duration of hypotension. ⋯ Three-day mortality was associated with delay to surgery ? 48 hours, whilst 30-day and 365-day mortality was associated with delay to surgery ≥ 48 hours, impaired cognition and cardiac/renal comorbidities. While the rate of acute kidney injury was similar to other studies, use of vasopressors and fluids to reduce the time spent at hypotensive levels failed to reduce this complication. Intra-operative hypotension at the levels observed in this cohort may not be an important determinant of acute kidney injury, postoperative mortality and length of stay.
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Patient-centred outcomes are increasingly recognised as crucial measures of healthcare quality. Days alive and at home up to 30 days after surgery (DAH30 ) is a validated and readily obtainable patient-centred outcome measure that integrates much of the peri-operative patient journey. However, the minimal difference in DAH30 that is clinically important to patients is unknown. ⋯ The median minimal clinically important difference for DAH30 was 3 days; this was consistent across a broad range of scenarios, including earlier discharge home, complications delaying hospital discharge and the requirement for admission to a rehabilitation unit. Discharge home earlier than anticipated and discharge home rather than to a rehabilitation facility were both rated as important (median score = 5). Empirical data on the minimal clinically important difference for DAH30 may be useful to determine sample size and to guide the non-inferiority margin for future clinical trials.