Anaesthesia
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Review
PROSPECT methodology for developing procedure-specific pain management recommendations: an update.
The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. ⋯ Future projects will use the Cochrane Collaboration risk of bias tool for quality of reporting of methodology and results. A modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach will be used for grading of level of evidence and strength of recommendations. Finally, the updated PROSPECT methodology addresses several other limitations and implements new factors that all add rigour and transparency to developing procedure-specific pain management recommendations.
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Oxytocin is widely used to prevent atonic postpartum haemorrhage after caesarean delivery. Initial treatment failure rates are high and inadequate dosing may contribute. Excessive doses, however, are associated with serious adverse effects. ⋯ In conclusion, we observed a large variation in serum oxytocin concentrations between individuals receiving similar doses of oxytocin and were unable to establish weight-based dosing of exogenous oxytocin at caesarean delivery. Our findings suggest that future studies on oxytocin pharmacokinetics would need large sample sizes. In the absence of such data, oxytocin dosing should continue to be guided by uterine tone assessments and adjusted according to a strategy based on the best evidence from dose-effect studies.
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Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. ⋯ Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.
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Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient-centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient-centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high-risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. ⋯ Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31-2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk-adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being -14.4 (-17.38 to -10.71), p < 0.001 on day 3, and -5.94 (-8.92 to -2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.
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Emergency airway management events are common, unpredictable and associated with high complication rates. This multicentre prospective observational study across eight acute NHS hospitals in southeast England reports the incidence and nature of non-theatre emergency airway management events. Data were collected from non-theatre emergency airway management, including adverse events, over a continuous 28-day window, and recorded on an electronic case report form. ⋯ Adverse outcomes during advanced airway management (excluding during cardiac arrest) occurred in 53/111 (48%) episodes, including hypoxia (desaturation to Sp O2 < 80% in 14/111, 13%) and hypotension (systolic blood pressure < 80 mmHg in 27/111, 25%). Adverse outcomes were not associated with time of day or experience level of airway practitioners. We conclude that there is a disparity between consultant presence for advanced airway interventions in- and out-of-hours; high utilisation of videolaryngoscopy and capnography, especially for advanced airway interventions; and a high incidence of hypotension and hypoxaemia, including critical values, during non-theatre airway management.