Articles: outcome.
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Angioneurotic oedema is a rare disease caused by Cl esterase inhibitor deficiency. Hereditary angioneurotic oedema includes type I (quantitative and functional) deficiency and type 11 (functional) deficiency. Its prophylactic treatment during pregnancy, based on danazol therapy if the fetus is male, may avoid acute attacks of generalized or laryngeal oedema. ⋯ Regional analgesia is indicated for labour or caesarean section to prevent pain and stress and to avoid the difficulties associated with laryngeal oedema and tracheal intubation. In the treatment of an acute attack, Cl esterase inhibitor concentrates (1500 units) may be given i.v. We present two cases, one of hereditary and one of acquired angioneurotic oedema, both presenting during pregnancy and both delivered vaginally under epidural analgesia with successful outcome.
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To consider the evidence for the beneficial effects of the current management guidelines in traumatic brain injury, and to highlight the important issues. ⋯ The impact of management guidelines in traumatic brain injury on patient outcome has been difficult to determine. However, there is a large body of uncontrolled evidence that suggests secondary global cerebral ischaemia-hypoxic insults are the major determinants in influencing outcome and that therapeutic interventions that maintain and defend cerebral perfusion pressures may improve outcome.
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To review the recent advances in ventilatory therapy for acute respiratory failure in children. ⋯ High frequency ventilation exists in three forms, although only high frequency oscillation appears to show any benefit in the management of acute respiratory failure refractory to conventional mechanical ventilation. Extracorporeal oxygenation has halved mortality in neonates with acute respiratory failure, and has been used successfully in non-neonate patients. Inhaled nitric oxide from 6 to 20 parts per million improves oxygenation in paediatric patients with acute respiratory failure and congenital heart disease (particularly in the presence of pulmonary arterial hypertension). Liquid ventilation or perfluorocarbon-associated gas exchange has also been used to treat acute respiratory failure in paediatric patients, with partial liquid ventilation particularly appearing to show promise.
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For logistical reasons sedation studies are often carried out in elective surgical patients and the results extrapolated to the general intensive care unit (ICU) population. We question the validity of this approach. We compared the two sedation regimens used in our general ICU in a trial structured to mimic clinical practice as closely as possible. ⋯ Both regimens produced rapid onset of acceptable sedation but undersedation appeared more common with the cheaper diazepam regimen. At least 140 patients should be studied to provide evidence applicable to the general ICU population. Used alone, a sedation score may be an inappropriate outcome measure for a sedation trial.
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Recent prospective controlled trials of induced moderate hypothermia (32-34 degrees C) for relatively short periods (24-48 h) in patients with severe head injury have suggested improvement in intracranial pressure control and outcome. It is possible that increased benefit might be achieved if hypothermia was maintained for more periods longer than 48 h, but there is little in the literature on the effects of prolonged moderate hypothermia in adults with severe head injury. We used moderate induced hypothermia (30-33 degrees C) in 43 patients with severe head injury for prolonged periods (mean 8 days, range 2-19 days). ⋯ Moderate hypothermia may be induced for more prolonged periods, and is a relatively safe and feasible therapeutic option in the treatment of selected patients with severe traumatic brain injury. Thus, further prospective controlled trials using induced hypothermia for longer periods than 48 h are warranted.