British journal of anaesthesia
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Despite improvements in the clinical management of aneurysmal subarachnoid haemorrhage over the last decade, delayed cerebral ischaemia (DCI) remains the single most important cause of morbidity and mortality in those patients who survive the initial bleed. The pathological mechanisms underlying DCI are still unclear and the calcium channel blocker nimodipine remains the only therapeutic intervention proven to improve functional outcomes after SAH. The recent failure of the drug clazosentan to improve functional outcomes despite reducing vasoconstriction has moved the focus of research into DCI away from cerebral artery constriction towards a more multifactorial aetiology. ⋯ A greater understanding of the significance of these pathophysiological mechanisms and potential genetic risk factors is required, if new approaches to the prophylaxis, diagnosis, and treatment of DCI are to be developed. Furthermore, objective and reliable biomarkers are needed for the diagnosis of DCI in poor grade SAH patients requiring sedation and to assess the efficacy of new therapeutic interventions. The purpose of this article is to appraise these recent advances in research into DCI, relate them to current clinical practice, and suggest potential novel avenues for future research.
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The intensified use of spinal anaesthesia (SPA) for Caesarean section significantly contributed to a decreased maternal mortality and morbidity. Nevertheless, one of the major side-effects is hypotension after SPA with potential negative effects on the fetus. Owing to discontinuous oscillometric measurements (non-invasive arterial pressure, NIAP), hypotensive episodes may be missed. Recently, a continuous NIAP measurement device (CNAP) with acceptable agreement with the mean invasive AP was introduced. We hypothesized that CNAP detects hypotensive episodes more reliably compared with NIAP measurements. ⋯ The CNAP device detected more hypotensive episodes after SPA and significantly lower AP compared with NIAP. AP monitoring based on CNAP may improve haemodynamic management in this patient population with potential benefit for the fetus.
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Randomized Controlled Trial Comparative Study
Randomized controlled trial comparing the McGrath videolaryngoscope with the C-MAC videolaryngoscope in intubating adult patients with potential difficult airways.
Difficult and failed intubations, although rarely encountered, are major causes of morbidity and mortality in the current anaesthetic practice. To reduce the incidence of difficult and failed intubations, several devices including the recently developed videolaryngoscopes are available. This randomized controlled study aims to compare the use of the McGrath videolaryngoscope with the C-MAC videolaryngoscope in adult patients with potential difficult airways. ⋯ The C-MAC videolaryngoscope allowed a quicker intubation time, fewer intubation attempts, and greater ease of intubation compared with the McGrath videolaryngoscope when used in patients with the Mallampati grade of ≥3.
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The i.v. anaesthetic propofol produces bronchodilatation. Airway relaxation involves reduced intracellular Ca(2+) ([Ca(2+)](i)) in airway smooth muscle (ASM) and lipid rafts (caveolae), and constitutional caveolin proteins regulate [Ca(2+)](i). We postulated that propofol-induced bronchodilatation involves caveolar disruption. ⋯ These novel data suggest a role for caveolae (specifically caveolin-1) in propofol-induced bronchodilatation. Due to its lipid nature, propofol may transiently disrupt caveolar regulation, thus altering ASM [Ca(2+)](i).
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Emergency laparotomy is a common intra-abdominal procedure. Outcomes are generally recognized to be poor, but there is a paucity of hard UK data, and reports have mainly been confined to single-centre studies. ⋯ This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.