British journal of anaesthesia
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Randomized Controlled Trial Comparative Study
aepEX monitor for the measurement of hypnotic depth in patients undergoing balanced xenon anaesthesia.
Previously, we showed a significant difference in the measurements of hypnotic depth by the bispectral index (BIS) and auditory-evoked potentials (AEPs) using the A-line autoregressive index during xenon anaesthesia. In the present study, we evaluate the alternative AEP-based auditory-evoked potential index (aepEX) for the measurement of hypnotic depth in patients undergoing general anaesthesia with xenon. ⋯ We found the aepEX monitor to provide index in the range of adequate depth of xenon anaesthesia, when combined with remifentanil infusion in intubated patients undergoing elective abdominal surgery.
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Randomized Controlled Trial
Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery.
Intraoperative fluid therapy regimens using oesophageal Doppler monitoring (ODM) to optimize stroke volume (SV) (goal-directed fluid therapy, GDT) have been associated with a reduction in length of stay (LOS) and complication rates after major surgery. We hypothesized that intraoperative GDT would reduce the time to surgical readiness for discharge (RfD) of patients having major elective colorectal surgery but that this effect might be less marked in aerobically fit patients. ⋯ Intraoperative SV optimization conferred no additional benefit over standard fluid therapy. In an aerobically fit subgroup of patients, GDT was associated with detrimental effects on the primary outcome.
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Many people care deeply about what happens to their own and their loved ones' bodies after death. It is therefore important to capture individuals' wishes and ensure that they are respected as far as practically possible. At the same time, healthcare professionals need to feel confident that they are morally entitled to do what they need to do to ensure that someone's wishes are fulfilled. ⋯ It attempts to reconcile the way in which people are required to express their wish to donate organs with the need to reassure and support the professionals, who will care for them if they become potential donors. Current donor registration processes leave some professionals feeling that donors have not consented in the usual manner to procedures, which might be necessary before death. It is suggested that this issue could be addressed without imposing information overload on prospective donors, by changing the way in which the wish to donate is understood and expressed.
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Implementation of the recommendations from the Organ Donation Taskforce has introduced for the first time into the UK a nationwide framework for deceased donation. This framework is based, in principle, upon a conviction that donation should be viewed as part of end-of-life care and that the actions often necessary to facilitate it become justified when donation is recognized to be consistent with the wishes and interests of a dying patient. The implementation of the Taskforce recommendations across the complex landscape of acute hospital care in the UK represents a challenging programme of change management that has three more or less distinct phases. ⋯ Implementation has focused heavily upon areas of practice where significant opportunities to increase donor numbers exist. It is recognized that the greatest challenge is to overcome the societal and clinical behaviours and beliefs that currently create barriers to donation. Although national audit data may point to some of these areas of practice, international comparisons suggest that differences in approach to the care of patients with catastrophic brain injury may have a profound influence on the size of the potential donor pool.
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Improving the consent rate for solid organ donation from deceased donors is a key component of strategies in the UK and other countries to increase the availability of organs for transplantation. In the UK, the law is currently clear on what forms consent may take, with the views of the individual expressed previously in life taking priority. Such views may have been expressed prospectively, via membership of the Organ Donor Register or by talking to family members. ⋯ Studies have examined why some families of potential donors refuse consent, while others have demonstrated a key set of 'modifiable' factors relating to the family approach. These include ensuring the right timing of a request in an appropriate setting, providing emotional support, and imparting specific information, particularly concerning the nature of brain death. If these are optimized and the right personnel with adequate training are involved in a planned process, then consent rates may be improved as reported in other countries with organized donation systems.