British journal of anaesthesia
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Patients experiencing massive haemorrhage are at high risk of developing coagulopathy through loss, consumption, and dilution of coagulation factors and platelets. It has been reported that plasma fibrinogen concentrations may reach a critical low level relatively early during bleeding, calling for replacement fibrinogen therapy. Cryoprecipitate has been widely used in the past, but more recently, a pasteurized fibrinogen concentrate has become available. We audited the effects of fibrinogen concentrate therapy on laboratory and clinical outcome in patients with massive haemorrhage. ⋯ Off-label substitution therapy with a fibrinogen concentrate generally improved global laboratory coagulation results and as supplementary intervention, appeared to diminish the requirements for RBC, FFP, and platelet substitution in this patient cohort.
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Randomized Controlled Trial
Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery.
Intraoperative stress may suppress the adaptive immune system. Abolished proinflammatory lymphocyte function is associated with higher risk of infection and postoperative complications. We hypothesized that thoracic epidural anaesthesia (TEA) reduces intraoperative stress and thus attenuates lymphocyte decrease and impairment of proinflammatory lymphocyte function. ⋯ Intraoperative use of thoracic epidural catheter reduced stress response and prevented stress-induced perioperative impairment of proinflammatory lymphocyte function.
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Randomized Controlled Trial Comparative Study
Airway scope and gum elastic bougie with Macintosh laryngoscope for tracheal intubation in patients with simulated restricted neck mobility.
/st> Airway Scope is a new videolaryngoscope which requires less cervical movement during intubation than direct laryngoscopy. Thus, in patients wearing a rigid cervical collar, we compared the efficacy of the Airway Scope and the gum elastic bougie with Macintosh laryngoscope during tracheal intubation. ⋯ /st> The Airway Scope shortens intubation time, is less likely to result in oesophageal intubation, and may offer a marginally higher intubation success rate in patients with simulated restricted neck mobility.
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Review Case Reports
Convulsions after ropivacaine 300 mg for brachial plexus block.
A healthy 18-yr-old male (weight 60 kg, height 167 cm), with a history of febrile convulsions in childhood, developed a grand mal convulsion 10 min after the second of two injections of ropivacaine 150 mg, both given incrementally 15 min apart (total 300 mg), for combined axillary/interscalene brachial plexus block. Treatment was with oxygen, lung ventilation, and i.v. midazolam, and the patient made a complete recovery. ⋯ Whether sub-clinical EEG changes identified after operation were related to this sensitivity cannot be determined, but review illustrates wide variation in both the dose and the plasma concentration of local anaesthetics associated with systemic toxicity. The UK recommended dose of ropivacaine for brachial plexus block is 225-300 mg according to stature.
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Comparative Study
Assessing fitness for surgery: a comparison of questionnaire, incremental shuttle walk, and cardiopulmonary exercise testing in general surgical patients.
Morbidity and mortality are higher in patients with poor preoperative cardiorespiratory reserve. This study aimed to ascertain fitness and therefore risk in elective patients, comparing three measures: Duke Activity Status Index (DASI) questionnaire, incremental shuttle walk test (ISWT), and cycle cardiopulmonary exercise testing (CPET). We looked for correlation between the measures and for thresholds on the questionnaire or shuttle test which could identify fit patients and render CPET unnecessary. ⋯ We found a significant correlation between the tests. However, many patients with poor questionnaire scores or shuttle walks had satisfactory CPET results. Hence, the ability of either simple test to determine risk in a heterogeneous surgical population is poor. CPET provides an objective measurement of cardiopulmonary fitness; however, evidence for this information improving patient outcome is limited and requires further research.