Masui. The Japanese journal of anesthesiology
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Frequency of using nitrous oxide (N2O) in anesthetic field decreased recently by the influence of the environmental problems and the widespread use of intravenous agents. In dental treatment, however, inhalation sedation using low concentration of N2O has been effectively used to relax dental patients. Nitrous oxide inhalation sedation for dental treatment generally involves the use of a combination of low-dose N2O and high-dose oxygen. ⋯ Also, high-dose oxygen would contribute to manage "(pre) syncope" due to pain stimuli. Thus, N2O inhalation sedation is effective for the dental treatment, although the leak of N2O affects the health of dental staffs. The present review described the advantage and harmful effects of N2O in dental management.
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To prevent catheter-related bloodstream infections (CRBSI), the use of maximal sterile barrier precautions (MSBP) during central venous catheter insertion, using a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, was recommended in the Centers for Disease Control and Prevention Guidelines. However, this recommendation is based on the evidence obtained by only one randomized controlled trial (RCT) in which the subject patients were outpatients for chemotherapy. Nevertheless, the recommendation is applied to any kind of clinical settings. ⋯ There were 5 out of 211 cases (2.4%) of CRBSI in the MSBP group and 6 out of 213 cases (2.8%) in the SSBP group (P = 0.77). These results suggest that further RCTs should be necessary in many clinical settings to reach a conclusion on this issue. We also address other evidences regarding prevention of CRBSI in this review.
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Acute Respiratory Distress Syndrome (ARDS) is a life threatening condition. There are several randomized placebo controlled trials (RCT) that tested ventilated and non-ventilated patient managements. Among them, only ARMA trial that compared mortality and ventilator free-days between low tidal volume ventilation and conventional ventilation (6 and 12 ml x kg(-1) predicted body weight, respectively) showed differences (31.0% vs., 39.8%, P = 0.007 and 12 +/- 11 vs. 10 +/- 11 days, P = 0.007, respectively). ⋯ Methylprednisolone iv administration starting between 7 and 13 days of the onset of ARDS increased the number of ventilator-free days and shock-free days; whereas, methylprednisolone treatment starting more than two weeks after the onset of ARDS increased the risk of death. There are no RCTs that positively showed the improvement in mortality by using any therapeutic agent. Based on basic science studies, molecules that enhance epithelial and endothelial cell proliferation and the therapies targeting on septic pathophysiology would be the target for future strategies.
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Appropriate and careful interpretation of results from clinical trials is essential for evidence-based medicine. Clinical trials for approval of new drugs and new indications are rigidly designed and conducted in highly selected patients for the safe and strict assessment of efficacy of drugs, and is associated with high internal validity but low generalizability of results. On the other hand, pragmatic trials for the assessment of effectiveness of treatment with approved drugs use less rigid design, for example, unmasked trial treatment and less strict selection of patients, and may be associated with high external but low internal validity. ⋯ However, they may be misled if component end points are of widely differing objectivity and importance to patients. Less objective end points in unmasked trials may also lead to overestimation of effects of intervention. There are many pitfalls in terms of the interpretation of the results from clinical trials, and they must be recognized for evidence-based medicine.
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Hyperglycemia is common in critically ill patients with approximately 90% of patients treated in an intensive care unit (ICU) developing blood glucose concentrations greater than 110 mg x dl(-1). Recently the international multicentre NICE-SUGAR study reported increased mortality with adopting intensive glucose control for critically ill patients and recent meta-analyses do not support this approach. ⋯ Unresolved issues include whether increased blood glucose variability is inherently harmful and whether even moderate hypoglycemia can be tolerated in the quest for tighter blood glucose control. Until another level I evidence will be available, clinicians would be well advised to hasten slowly and abide by the age-old adage to "first, do no harm".