British journal of anaesthesia
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Editorial Comment
'Where there's smoke': longitudinal cognitive disintegration after postoperative delirium?
Postoperative delirium is an important complication of surgery and is associated with poor long-term cognitive outcomes, although the neural basis underlying this relationship is poorly understood. Neuroimaging studies and network-based approaches play an important role in our understanding of the mechanism by which delirium relates to longitudinal cognitive decline. A recent resting state functional MRI study is reviewed, which shows reduced global connectivity up to 3 months after delirium, supporting recent models of delirium and opening the door for applying this approach to understanding the complex inter-relationship between delirium and dementia.
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Comment Letter Randomized Controlled Trial
Dexmedetomidine administration during brain tumour resection and postoperative delirium: a randomised controlled trial. Comment on Br J Anaesth 2023; 130: e307-e316.
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Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. ⋯ Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.
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Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. ⋯ Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.
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Observational Study
Intraoperative hydromorphone decreases postoperative pain: an instrumental variable analysis.
Intraoperative administration of short-acting opioids might lead to increased postoperative pain and opioid requirements. There are few data describing the effects of intermediate-duration opioids such as hydromorphone on these outcomes. We have previously shown that a switch from a 2 mg to a 1 mg vial of hydromorphone was associated with decreased intraoperative dose administration. As presentation dose affected intraoperative hydromorphone administration and was unrelated to other policy changes, it could serve as an instrumental variable, assuming significant secular trends were not present during the study period. ⋯ This study suggests that intraoperative administration of intermediate-duration opioids does not cause the same effects as short-acting opioids with respect to postoperative pain. Instrumental variables can be used to estimate causal effects using observation data when unmeasured confounding is present.