British journal of anaesthesia
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Blood transfusion saves many lives but carries significant risk of injury. Currently, red blood cell (RBC) concentrates can be stored up to 42 days. Concerns have recently been raised about the safety and efficacy of transfusing stored RBCs. ⋯ A number of clinical studies, mostly observational or retrospective and from a single centre, have reported an association between transfusion of older RBCs and increased clinically significant outcomes, such as increased morbidity and mortality in certain patient populations, including trauma, critical care, and cardiac surgery. Others, however, have failed to indicate an influence of RBC age on outcome. The quality of evidence is currently too poor to make recommendations to change current transfusion practice; however, the transfusion community looks forward to the results of randomized trials currently addressing the long-standing question regarding the effects of RBC storage on clinically significant outcomes.
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Observational Study
Neuro-ventilatory efficiency during weaning from mechanical ventilation using neurally adjusted ventilatory assist.
Neuro-ventilatory efficiency (NVE), defined as the tidal volume to electrical diaphragm-activity ratio (VT/EAdi) at the beginning and end of the weaning process after acute hypoxaemic respiratory failure, may provide valuable information about patient recovery. ⋯ These results suggest that in patients after respiratory failure and prolonged mechanical ventilation, changes in VT and NVE, between SBTs are indicative of patient recovery. Larger clinical trials are needed to clarify whether changes in NVE reliably predict weaning in patients ventilated with NAVA.
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Transfusion of allogeneic plasma has been a life-saving measure for decades in patients with severe trauma or suffering from major surgical blood loss. The safety of allogeneic blood components has improved in terms of pathogen transmission, but haemostatic efficacy of plasma is hindered by the large volume and time required for thawing and infusion. ⋯ The haemostatic defect in perioperative patients is often multifactorial, and therefore careful clinical judgement and timely coagulation testing must be exercised before the administration of factor concentrates. In this review, the rationale for including factor concentrates in perioperative haemostatic management will be discussed in conjunction with the limitations of plasma transfusion.
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The prevalence of type 2 diabetes mellitus and the potential for perioperative dysglycaemia (hyperglycaemia, hypoglycaemia, stress-induced hyperglycaemia, or glucose variability) continue to increase dramatically. The majority of investigations on perioperative glycaemic control focused on critically ill patients and concentrated on goals of therapy, level of intensity of insulin infusion, feeding regimes, concerns over hypoglycaemia, and promulgation of recent guidelines calling for less strict glucose control. ⋯ In the heterogeneous adult perioperative population, it is unlikely that one standard of perioperative glycaemic control is appropriate for all patients. This review presents recent evidence and expert guidance to aid preoperative assessment, intraoperative management, and postoperative care of the dysglycaemic adult patient.
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Obstructive sleep apnoea (OSA) has become a major public health concern as its incidence and severity have increased in tandem with the obesity epidemic. In children, OSA is now recognized as a common disorder and can be associated with significant morbidity. OSA belongs to a spectrum of diagnoses known as sleep-related breathing disorders in which the airway is completely (apnoea) or partially (hypopnoea) occluded during sleep despite continued respiratory efforts. ⋯ A thorough understanding of the pathophysiology of OSA, careful and complete preoperative assessment, meticulous intraoperative and postoperative management, and early recognition of potential perioperative complications are essential to optimization of outcomes. The safe anaesthetic management of a child with OSA requires an anaesthetic technique tailored to the underlying aetiology and severity of OSA and the surgical procedure. This review focuses on the epidemiology, pathogenesis, and diagnosis of OSA, and the state-of-the-art and future directions in the perioperative management of children with OSA.