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Journal Cover Anaesthesia
  [SJR: 1.404]   [H-I: 88]   [141 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0003-2409 - ISSN (Online) 1365-2044
   Published by John Wiley and Sons Homepage  [1589 journals]
  • The association of pre-operative home accelerometry with cardiopulmonary
           exercise variables
    • Authors: H. W. Cui; G. S. Kirby, K. Surmacz, C. Hargrove, J. Griffiths, B. W. Turney
      Abstract: We investigated the association of pre-operative activity, reported by the Duke Activity Score Index, Short Form-12 and measured by an accelerometer worn at home, with five cardiopulmonary exercise variables: peak power; peak oxygen consumption; anaerobic threshold; and ventilatory equivalents for oxygen and carbon dioxide. Fifty patients scheduled for major surgery underwent a standard pre-operative cardiopulmonary exercise test and wore a chest-mounted triaxial accelerometer for a mean (SD) duration of 3.2 (0.4) days. The Duke Activity Score Index and six accelerometer variables were significantly correlated with all five cardiopulmonary exercise variables, Pearson correlation coefficients 0.5–0.7, p = 0.02 to p 
      PubDate: 2017-12-12T00:46:03.838557-05:
      DOI: 10.1111/anae.14181
  • Peri-operative management of patients with type-2 diabetes mellitus
           undergoing non-cardiac surgery using liraglutide,
           glucose–insulin–potassium infusion or intravenous insulin bolus
           regimens: a randomised controlled trial
    • Authors: J. A. W. Polderman; S. C. J. Steen, B. Thiel, M. B. Godfried, P. L. Houweling, M. W. Hollmann, J. H. DeVries, B. Preckel, J. Hermanides
      Abstract: In this open-label multicentre randomised controlled trial, we investigated three peri-operative treatment strategies to lower glucose and reduce the need for rescue insulin in patients aged 18–75 years with type-2 diabetes mellitus undergoing non-cardiac surgery. Patients were randomly allocated using a web-based randomisation program to premedication with liraglutide (liraglutide group), glucose–insulin–potassium infusion (insulin infusion group) or insulin bolus regimen (insulin bolus group), targeting a glucose < 8.0 mmol.l−1. The primary outcome was the between group difference in median glucose levels 1 h after surgery. We analysed 150 patients (liraglutide group n = 44, insulin infusion group n = 53, insulin bolus group n = 53) according to the intention-to-treat principle. Median (IQR [range]) plasma glucose 1 h postoperatively was lower in the liraglutide group compared with the insulin infusion and insulin bolus groups (6.6 (5.6–7.7 [4.2–13.5]) mmol.l−1 vs. 7.5 (6.4–8.3 [3.9–16.6]) mmol.l−1 (p = 0.026) and 7.6 (6.4–8.9 [4.7–13.2]) mmol.l−1) p = 0.006, respectively). The incidence of hypoglycaemia and postoperative complications did not differ between the groups. Six patients had pre-operative nausea in the liraglutide group, of which two had severe nausea, compared with no patients in the insulin infusion and insulin bolus groups (p = 0.007). The pre-operative administration of liraglutide stabilised peri-operative plasma glucose levels and reduced peri-operative insulin requirements, at the expense of increased pre-operative nausea rates.
      PubDate: 2017-12-12T00:32:41.012906-05:
      DOI: 10.1111/anae.14180
  • Intravenous dexamethasone for prophylaxis of postoperative nausea and
           vomiting after administration of long-acting neuraxial opioids: a
           systematic review and meta-analysis
    • Authors: S. Grape; I. Usmanova, K. R. Kirkham, E. Albrecht
      Abstract: Long-acting neuraxial opioids provide excellent analgesia after surgery, but are associated with higher rates of postoperative nausea and vomiting. Dexamethasone effectively prevents postoperative nausea and vomiting after general anaesthesia, but its value in patients receiving long-acting neuraxial opioids is undetermined. Therefore, the objective of this meta-analysis was to assess the prophylactic anti-emetic efficacy of intravenous (i.v.) dexamethasone in this population. The study methodology followed the PRISMA statement guidelines. The primary outcome was the need for rescue anti-emetics during the first 24 postoperative hours, analysed according to the dose of dexamethasone (low-dose 2.5–5.0 mg; intermediate dose 6.0–10.0 mg), timing of administration (beginning or end of surgery) and route of long-acting opioid administration (intrathecal or epidural). Additionally, the rates of complications (restlessness, infection, hyperglycaemia) were sought. Thirteen trials were identified, representing a total of 1111 patients. When compared with placebo, intravenous dexamethasone reduced the need for rescue anti-emetics (risk ratio (95%CI) 0.44 (0.35–0.56); I2 = 43%; p < 0.00001; quality of GRADE evidence: moderate), without differences between dexamethasone doses (p for sub-group difference = 0.67), timing of administration (p for sub-group difference = 0.32) or route of long-acting opioid (p for sub-group difference = 0.10). No patients developed infection or restlessness among trials that sought these complications. No trial measured blood glucose levels. In conclusion, there is enough evidence to state that intravenous dexamethasone provides effective anti-emetic prophylaxis during the first 24 postoperative hours in patients who receive long-acting neuraxial opioids.
      PubDate: 2017-12-11T06:35:38.847399-05:
      DOI: 10.1111/anae.14166
  • Pilot multi-centre randomised trial of the impact of pre-operative focused
           cardiac ultrasound on mortality and morbidity in patients having surgery
           for femoral neck fractures (ECHONOF-2 pilot)
    • Authors: D. J. Canty; J. Heiberg, Y. Yang, A. G. Royse, S. Margale, N. Nanjappa, D. Scott, A. Maier, D. I. Sessler, A. Chuan, A. Palmer, A. Bucknill, C. French, C. F. Royse
      Abstract: Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound – and therefore supports a large randomised clinical trial.
      PubDate: 2017-12-11T06:30:26.736736-05:
      DOI: 10.1111/anae.14130
  • Between evidence and commerce – the case of sufentanil sublingual
           tablet systems
    • Authors: C. Bantel; H. C. Laycock
      PubDate: 2017-12-08T07:06:06.579094-05:
      DOI: 10.1111/anae.14037
  • Pharmacokinetics and pharmacodynamics of sublingual sufentanil for
           postoperative pain management
    • Authors: T. Donk; S. Ward, R. Langford, A. Dahan
      Abstract: Achieving successful treatment of postoperative pain remains a challenge. Recently, a sufentanil sublingual tablet system has been developed for treatment of moderate-to-severe postoperative pain. The phenylpiperidine sufentanil is a potent analgesic that rapidly crosses the blood–brain barrier and selectively activates central μ-opioid receptors. The system makes use of a hand-held dispenser system, which contains forty 15-μg sufentanil sublingual micro-tablets. The patient can release one tablet at 20-min intervals using a unique radiofrequency adhesive tag, which is wrapped around the patient's thumb. In this review, the authors discuss the pharmacology of sublingual sufentanil with reference to its suitability in the treatment of postoperative pain, the current evidence for the sublingual sufentanil system in postoperative pain treatment, and advantages and limitations of the sublingual system. We conclude that sufentanil is suited for the transmucosal route due to its pharmacokinetic profile, including rapid onset, absence of active metabolites and low tissue accumulation. The efficacy and safety of the sufentanil sublingual tablet system has been shown in over 600 patients in a limited set of studies; further independent studies are required to determine the position of the system among other forms of postoperative pain treatment. We conclude that the sublingual sufentanil tablet system allows effective pain relief, and allows patients to control their own pain relief and early postoperative mobility.
      PubDate: 2017-12-08T07:00:54.938974-05:
      DOI: 10.1111/anae.14132
  • Recovery characteristics of patients receiving either sugammadex or
           neostigmine and glycopyrrolate for reversal of neuromuscular block: a
           randomised controlled trial
    • Authors: M. J. Paech; R. Kaye, C. Baber, E. A. Nathan
      Abstract: Sugammadex more rapidly and reliably reverses rocuronium-induced neuromuscular block compared with neostigmine, but it is not known if subsequent patient outcomes, including nausea, vomiting and other aspects of recovery are modified. In this study, we compared the recovery characteristics of sugammadex and neostigmine/glycopyrrolate following reversal of neuromuscular block. This was a single-centre, randomised, blinded, parallel-group clinical trial in women undergoing elective day-surgical laparoscopic gynaecological surgery, with a standardised general anaesthesia regimen that included rocuronium. Neuromuscular block was reversed with either sugammadex 2−1 or neostigmine 40 μ−1 and glycopyrrolate 400 μg. The primary outcome was the incidence of nausea and vomiting during the first six postoperative hours. Secondary outcomes included other measures of postoperative recovery such as patient symptoms and recovery scores. Three-hundred and four women were analysed by intention-to-treat (sugammadex n = 151, neostigmine n = 153), which included four major protocol violations. There was no significant difference between sugammadex and neostigmine groups in the incidence of early nausea and vomiting (49.0% vs. 51.0%, respectively; OR 0.92, 95%CI 0.59–1.45; p = 0.731). Double vision (11.5% vs. 20.0%; p = 0.044) and dry mouth (71.6% vs. 85.5%; p = 0.003) were less common after sugammadex. Sedation scores at 2 h were also lower after sugammadex (median (IQR [range]) 0 (0-3 [0-10]) vs. 2 (0-4.[0-10]); p = 0.021). Twenty-four-hour recovery scores were not significantly different between groups. Reversal with sugammadex in this patient population did not reduce postoperative nausea or vomiting compared with neostigmine/glycopyrrolate.
      PubDate: 2017-12-07T01:36:12.093491-05:
      DOI: 10.1111/anae.14174
  • Postoperative outcomes following cardiac surgery in non-anaemic
           iron-replete and iron-deficient patients – an exploratory study
    • Authors: L. F. Miles; S. A. Kunz, L. H. Na, S. Braat, K. Burbury, D. A. Story
      Abstract: Iron deficiency anaemia is strongly associated with poor outcomes after cardiac surgery. However, pre-operative non-anaemic iron deficiency (a probable anaemia precursor) has not been comprehensively examined in patients undergoing cardiac surgery, despite biological plausibility and evidence from other patient populations of negative effect on outcome. This exploratory retrospective cohort study aimed to compare an iron-deficient group of patients undergoing cardiac surgery with an iron-replete group. Consecutive non-anaemic patients undergoing elective coronary artery bypass grafting or single valve replacement in our institution between January 2013 and December 2015 were considered for inclusion. Data from a total of 277 patients were analysed, and were categorised by iron status and blood haemoglobin concentration into iron-deficient (n = 109) and iron-replete (n = 168) groups. Compared with the iron-replete group, patients in the iron-deficient group were more likely to be female (43% vs. 12%, iron-replete, respectively); older, mean (SD) age 64.4 (9.7) vs. 63.2 (10.3) years; and to have a higher pre-operative EuroSCORE (median IQR [range]) 3 (2–5 [0–10]) vs. 3 (2–4 [0–9]), with a lower preoperative haemoglobin of 141.6 (11.6) vs. 148.3 (11.7) g.l−1. Univariate analysis suggested that iron-deficient patients had a longer hospital length of stay (7 (6–9 [2–40]) vs. 7 (5–8 [4–23]) days; p = 0.013) and fewer days alive and out of hospital at postoperative day 90 (83 (80–84 [0–87]) vs. 83 (81–85 [34–86]), p = 0.009). There was no evidence of an association between iron deficiency and either lower nadir haemoglobin or higher requirement for blood products during inpatient stay. After adjusting the model for pre-operative age, sex, renal function, EuroSCORE and haemoglobin, the mean increase in hospital length of stay in the iron-deficient group relative to the iron-replete group was 0.86 days (bootstrapped 95%CI −0.37 to 2.22, p = 0.098). This exploratory study suggests there is weak evidence of an association between non-anaemic iron deficiency and outcome after cardiac surgery after controlling for potentially confounding variables.
      PubDate: 2017-12-02T01:30:44.211401-05:
      DOI: 10.1111/anae.14115
  • Determination of the optimal programmed intermittent epidural bolus volume
           of bupivacaine 0.0625% with fentanyl 2 μ−1 at a fixed interval of
           forty minutes: a biased coin up-and-down sequential allocation trial
    • Authors: P. Zakus; C. Arzola, R. Bittencourt, K. Downey, X. Y. Ye, J. C. Carvalho
      Abstract: The optimum time interval for 10 ml boluses of bupivacaine 0.0625% + fentanyl 2 μ−1 as part of a programmed intermittent epidural bolus regimen has been found to be 40 min. This regimen was shown to be effective without the use of supplementary patient-controlled epidural analgesia boluses in 90% of women during the first stage of labour, although with a rate of sensory block to ice above T6 in 34% of women. We aimed to determine the optimum programmed intermittent epidural bolus volume at a 40 min interval to provide effective analgesia in 90% of women (EV90) during the first stage of labour, without the use of patient-controlled epidural analgesia. We performed a prospective double-blind dose-finding study using the biased coin up-and-down sequential allocation method in 40 women. The estimated EV90 was 11.0 (95%CI 10.0–11.7) ml with the isotonic regression method and 10.7 (95%CI 10.3–11.0) ml with the truncated Dixon and Mood method. Overall, 18 women had a sensory block above T6, and 37 women exhibited no motor block. No women required treatment for hypotension. In conclusion, it is not possible to reduce the programmed intermittent epidural bolus volume from 10 ml, used in our current regimen, without compromising the quality of analgesia. Using this regimen, a high proportion of women will develop a sensory block above T6.
      PubDate: 2017-12-02T01:25:33.884372-05:
      DOI: 10.1111/anae.14159
  • Risk of epilepsy in surgical patients undergoing general or neuraxial
    • Authors: H. C. Chang; C. C. Liao, C. C. Chang, S. Y. Huang, C. C. Yeh, C. J. Hu, Y. G. Cherng, T. L. Chen
      Abstract: Limited information is available on the risks of epilepsy after surgery in patients receiving general or neuraxial anaesthesia. Using Taiwan's National Health Insurance Research Database, we identified 1,478,977 patients aged ≥ 20 years who underwent surgery (required general or neuraxial anaesthesia with hospitalisation for more than one day) between 2004 and 2011. We selected 235,066 patients with general anaesthesia and 235,066 patients with neuraxial anaesthesia using a frequency-matching procedure for age and sex. We did not study those with co-existing epilepsy-related risk factors. The adjusted rate ratios (RRs) and 95% confidence intervals (CIs) of newly diagnosed epilepsy 1 year after surgery associated with general anaesthesia were analysed in the multivariate Poisson regression model. The one-year incidence of postoperative epilepsy for patients with general anaesthesia and neuraxial anaesthesia were 0.41 and 0.32 per 1000 persons, respectively, and the corresponding RR was 1.27 (95%CI 1.15–1.41). The association between general anaesthesia and postoperative epilepsy was significant in men (RR = 1.22; 95%CI 1.06–1.40), women (RR = 1.33; 95%CI 1.15–1.55) and 20–39-year-old patients. The risk of postoperative epilepsy increased in patients with general anaesthesia who had co-existing medical conditions and postoperative complications.
      PubDate: 2017-11-27T04:25:49.258385-05:
      DOI: 10.1111/anae.14099
  • A randomised controlled trial comparing high-flow nasal oxygen with
           standard management for conscious sedation during bronchoscopy
    • Authors: N. Douglas; I. Ng, F. Nazeem, K. Lee, P. Mezzavia, R. Krieser, D. Steinfort, L. Irving, R. Segal
      Abstract: Traditional conscious sedation for endobronchial ultrasound procedures places patients at risk of desaturation, and high-flow nasal oxygen may reduce the risk. We designed a parallel-group randomised controlled trial of high-flow nasal oxygen at a flow rate of 30–70 l.min−1 via nasal cannulae, compared with standard oxygen therapy at 10 l.min−1 via a bite block in adults planned for conscious sedation for endobronchial ultrasound. The primary outcome was the proportion of patients experiencing desaturation (defined as SpO2 < 90%). Secondary outcomes included oxygen saturation after pre-oxygenation, lowest oxygen saturation during procedure, number of hypoxic episodes, duration of hypoxia, end-procedure end-tidal CO2, satisfaction scores and complications. Thirty participants were allocated to each group. Baseline patient characteristics, procedure time and anaesthetic agents used were similar between the groups. Desaturation occurred in 4 out of 30 patients allocated to the high-flow nasal oxygen group, compared with 10 out of 30 allocated to the standard oxygenation group, a non-significant difference (p = 0.07) with intention to treat analysis. The difference was significant (p = 0.047) when using a per-protocol analysis. Oxygen saturation after pre-oxygenation and the lowest oxygen saturation during procedure were significantly higher in the high-flow nasal oxygen group compared with the standard oxygenation group; median (IQR [range] 100 (99–100 [93–100]) vs. 98 (97–99 [94–100]), p = 0.0001 and 97.5 (94–99 [77–100]) vs. 92 (88–95 [79–98]), p < 0.001, respectively. There were no differences in other secondary outcomes. Although high-flow nasal oxygen may prevent desaturation due to some causes, it does not protect against hypoxaemia in all circumstances.
      PubDate: 2017-11-24T06:40:39.283241-05:
      DOI: 10.1111/anae.14156
  • Volume responsiveness assessed by passive leg raising and a fluid
           challenge: a critical review focused on mean systemic filling pressure
    • Authors: K. Cooke; R. Sharvill, S. Sondergaard, A. Aneman
      Abstract: This review applied cardiovascular principles relevant to the physiology of venous return in interpreting studies on the utility of a passive leg-raising manoeuvre to identify patients who do (responders) or do not respond to a subsequent intravenous volume challenge with an increase in cardiac output. Values for cardiac output, mean arterial and central venous pressure, and the calculated cardiovascular variables mean systemic filling pressure analogue, heart efficiency, cardiac power indexed by volume state and volume efficiency, before and after passive leg raising as well as before and after fluid volume challenge, were extracted from published studies. Eleven studies including 572 patients and 52% responders were analysed. Cardiac output increased by 12% in responders during passive leg raising and by 22% following a volume challenge. No statistically significant differences were found between responders and non-responders in cardiac output, mean arterial or central venous pressure before the passive leg-raising manoeuvre or the volume challenge. In contrast, the calculated mean (SD) systemic filling pressure analogue, reflecting the intravascular volume, was significantly lower in responders (14.2 (1.8) mmHg) than non-responders (17.5 (3.4) mmHg; p = 0.007) before the passive leg-raising manoeuvre, as well as before fluid volume challenge (14.6 (2.2) mmHg vs. 17.6 (3.5) mmHg, respectively; p = 0.02). The scalar measure volume efficiency was higher in responders at 0.35 compared with non-responders at 0.10. Non-responders also demonstrated deteriorating heart efficiency of −15% and cardiac power of −7% when given an intravenous fluid volume challenge. The results demonstrate that the calculation of mean systemic filling pressure analogue and derived variables can identify patients likely to respond to a fluid volume challenge and provides scalar results rather than merely a dichotomous outcome of responder or non-responder.
      PubDate: 2017-11-24T06:36:11.074603-05:
      DOI: 10.1111/anae.14162
  • Time to stop using uncuffed tracheal tubes in children'
    • Authors: C. R. Bailey
      PubDate: 2017-11-23T06:35:31.590663-05:
      DOI: 10.1111/anae.14163
  • Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled
           trial comparing leak, tidal volume and complications
    • Authors: N. A. Chambers; A. Ramgolam, D. Sommerfield, G. Zhang, T. Ledowski, M. Thurm, M. Lethbridge, M. Hegarty, B. S. von Ungern-Sternberg
      Abstract: Cuffed tracheal tubes are increasingly used in paediatric anaesthetic practice. This study compared tidal volume and leakage around cuffed and uncuffed tracheal tubes in children who required standardised mechanical ventilation of their lungs in the operating theatre. Children (0–16 years) undergoing elective surgery requiring tracheal intubation were randomly assigned to receive either a cuffed or an uncuffed tracheal tube. Assessments were made at five different time-points: during volume-controlled ventilation 6−1, PEEP 5 cmH2O and during pressure-controlled ventilation 10 cmH2O / PEEP 5 cmH2O. The pressure-controlled ventilation measurement time-points were: just before a standardised recruitment manoeuvre; just after recruitment manoeuvre; 10 min; and 30 min after the recruitment manoeuvre. Problems and complications were recorded. During volume-controlled ventilation, leakage was significantly less with cuffed tracheal tubes than with uncuffed tracheal tubes; in−1, median (IQR [range]) 0.20 (0.13–0.39 [0.04–0.60]) vs. 0.82 (0.58–1.38 [0.24–4.85]), respectively, p < 0.001. With pressure-controlled ventilation, leakage was less with cuffed tracheal tubes and stayed unchanged over a 30-min period, whereas with uncuffed tracheal tubes, leakage was higher and increased further over the 30-min period. Tidal volumes were higher in the cuffed group and increased over time, but in the uncuffed group were lower and decreased over time. Both groups showed an increase in tidal volumes following recruitment manoeuvres. There were more short-term complications with uncuffed tracheal tubes, but no major complications were recorded in either group at long-term follow-up. With standardised ventilator settings, cuffed tracheal tubes produced better ventilation characteristics compared with uncuffed tracheal tubes during general anaesthesia for routine elective surgery.
      PubDate: 2017-11-23T06:30:22.21788-05:0
      DOI: 10.1111/anae.14113
  • Decision-making in response to respiratory veno-venous extracorporeal
           membrane oxygenation referrals: is current practice precise enough'
    • Authors: M. Charlesworth; A. D. Ashworth, J. M. Barker
      PubDate: 2017-11-23T06:15:33.393532-05:
      DOI: 10.1111/anae.14155
  • Acceptance and transfer to a regional severe respiratory failure and
           veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors
           and outcomes
    • Authors: S. A. Gillon; K. Rowland, M. Shankar-Hari, L. Camporota, G. W. Glover, D. L. A. Wyncoll, N. A. Barrett, N. Ioannou, C. I. S. Meadows
      Abstract: The use of extracorporeal membrane oxygenation for respiratory failure is high risk and resource intensive. In England, five centres provide this service and patients who are referred have four possible outcomes: declined transfer due to perceived futility; accepted in principle but remain at the referring centre with ongoing surveillance; retrieved using conventional ventilation; or retrieved on extracorporeal support. The decision-making process leading to these outcomes has not previously been examined. We evaluated referrals to one centre and identified factors associated with each decision outcome. Five hundred and sixty-four patients were analysed from January 2012 to October 2015. One hundred and fifty-seven patients were declined; multivariate analysis demonstrated associated factors to be: age (odds ratio (95% confidence interval) 1.05 (1.04–1.07)); immunocompromise (4.95 (2.58–9.67)); lactate (1.11 (1.01–1.22)); duration of ventilation (1.08 (1.04–1.14)); and cardiac failure (3.22 (1.04–10.51)). Factors associated with the decision to retrieve an accepted patient were: plateau pressure (1.05 (1.01–1.10)); ratio of arterial oxygen partial pressure to fractional inspired oxygen (0.89 (0.85–0.93)); partial pressure of carbon dioxide in arterial blood (1.13 (1.03–1.25)); and the absence of non-pulmonary infection (0.31 (0.15–0.61)). Only pH was independently associated with the decision to transfer on extracorporeal support (0.020 (0.002–0.017)). Six-month survival in the declined, non-retrieved, conventionally retrieved and extracorporeal-retrieved groups was 16.6%, 71.1%, 76.7% and 72.1%, respectively, substantially supporting the decision-making model. Survival in the accepted group exceeds that reported previously. However, a proportion of those declined do survive and some remotely managed patients die. This suggests the approach does not account for some important survival-determining factors.
      PubDate: 2017-11-23T06:05:28.383333-05:
      DOI: 10.1111/anae.14083
  • The effect of 6% hydroxyethyl starch (130/0.4) on acute kidney injury in
           paediatric cardiac surgery: a prospective, randomised trial
    • Authors: H.-W. Oh; J.-H. Lee, H.-C. Kim, E.-H. Kim, I.-K. Song, H.-S. Kim, J.-T. Kim
      Abstract: We have evaluated the effect of a colloid solution on acute kidney injury in paediatric cardiac surgery. A total of 195 patients were ramdomly divided into an hydroxyethyl starch group and a control group. In the starch group, 6% hydroxyethyl starch 130/0.4 (Volulyte®) was used as the primary fluid for volume resuscitation but was limited to 30−1. In the control group, only crystalloid fluid was used during the peri-operative period. The incidence of acute kidney injury, peri-operative transfusion, clinical outcomes and laboratory data were compared. The incidence of acute kidney injury determined by Paediatric Risk, Injury, Failure, Loss, End-stage renal disease (pRIFLE) and Acute Kidney Injury Network (AKIN) criteria were no different between the two groups (starch group 40.8% vs. control group 30.0%; p = 0.150 using pRIFLE; 19.6% vs. 21.1% respectively, p = 0.602 using AKIN). There were no differences in clinical outcomes such as mortality, major adverse events, intensive care unit stay or duration of mechanical ventilation. Clotting time as measured using rotational thromboelastometry (ROTEM) was prolonged, and clot firmness after 10 min and maximal clot firmness were shorter in the starch group compared with the control group after sternal closure. There was no difference in transfusion between the two groups. Patients with acute kidney injury had worse clinical courses than those without acute kidney injury. We conclude that intra-operative use of 6% hydroxyethyl starch 130/0.4 up to 30−1 was not associated with postoperative acute kidney injury in paediatric cardiac patients.
      PubDate: 2017-11-17T23:20:24.763396-05:
      DOI: 10.1111/anae.14129
  • Defining sepsis on the wards: results of a multi-centre point-prevalence
           study comparing two sepsis definitions
    • Authors: T. Szakmany; R. Pugh, M. Kopczynska, R. M. Lundin, B. Sharif, P. Morgan, G. Ellis, J. Abreu, S. Kulikouskaya, K. Bashir, L. Galloway, H. Al-Hassan, T. Grother, P. McNulty, S. T. Seal, A. Cains, M. Vreugdenhil, M. Abdimalik, N. Dennehey, G. Evans, J. Whitaker, E. Beasant, C. Hall, M. Lazarou, C. V. Vanderpump, K. Harding, L. Duffy, A. Guerrier Sadler, R. Keeling, C. Banks, S. W. Y. Ng, S. Y. Heng, D. Thomas, E. W. Puw, I. Otahal, C. Battle, O. Minik, R. A. Lyons, J. E. Hall,
      Abstract: Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54–75%) and specificity of 47% (41–53%); SEPSIS-3 criteria had a sensitivity of 86% (76–92%) and specificity of 32% (27–38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5–5.6) and 1.6 (1.3–2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63–0.76)), followed by NEWS (0.58 (0.51–0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49–0.61)) and quickSOFA score (0.56 (0.49–0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction.
      PubDate: 2017-11-17T23:10:37.856232-05:
      DOI: 10.1111/anae.14062
  • A systematic review of the incidence of and risk factors for postoperative
           atrial fibrillation following general surgery
    • Authors: R. Chebbout; E. G. Heywood, T. M. Drake, J. R. L. Wild, J. Lee, M. Wilson, M. J. Lee
      Abstract: Atrial fibrillation is a common cardiac arrhythmia and can occur de novo following a surgical procedure. It is associated with increased inpatient and long-term mortality. There is limited evidence concerning new-onset atrial fibrillation following abdominal surgery. This study aimed to identify the prevalence of and risk factors for postoperative atrial fibrillation in the general surgical population. A systematic search of the Embase, MEDLINE and Cochrane (CENTRAL) databases was conducted. Studies were included in the review if they reported cases of new-onset atrial fibrillation within 30 days of the index operation. Results were evaluated qualitatively due to substantial clinical heterogeneity. Incidence rates were pooled using a weighted random-effects meta-analysis model. A total of 835 records were initially identified, from which 32 full texts were retrieved. Following review, 13 studies were included that involved 52,959 patients, of whom 10.94% (95%CI 7.22–15.33) developed atrial fibrillation. Five studies of patients undergoing oesophagectomy (n = 376/1923) had a weighted average rate of 17.66% (95%CI 12.16–21.47), compared with 7.63% (95%CI 4.39–11.98) from eight studies of non-oesophageal surgery (n = 2927/51,036). Identified risk factors included: increasing age; history of cardiac disease; postoperative complications, particularly, sepsis, pneumonia and pleural effusions. New-onset postoperative atrial fibrillation is common, and is more frequent after surgery involving the thorax. Future work should focus on stratifying risk to allow targeted prophylaxis of atrial fibrillation and other peri-operative complications.
      PubDate: 2017-11-04T01:45:24.069355-05:
      DOI: 10.1111/anae.14118
  • Effect of sufentanil on bispectral index in the elderly
    • Authors: T. Valence; N. Elia, C. Czarnetzki, L. Dumont, M. R. Tramèr, C. Lysakowski
      Abstract: We examined the impact of adding sufentanil during anaesthesia induction with propofol on bispectral index values in elderly patients (≥ 65 years). Patients were randomly assigned to receive a target-controlled sufentanil infusion (effect-site concentration of 0.3−1) or matching placebo, followed by a target-controlled propofol induction (initial effect-site concentration of 0.5 μ−1; step-wise increase of 0.5 μ−1) until loss of consciousness defined as an Observer's Assessment of Alertness/Sedation score < 2. Seventy-one patients (sufentanil 35, placebo 36) completed the study. Mean (SD) age was 72.3 (5.8) years; 41% were women. At loss of consciousness, mean (SD) bispectral index value was 75.0 (8.6) with sufentanil and 70.0 (8.0) with placebo; mean difference −5.0 (95% confidence interval −8.9 to −1.1), p = 0.013. Post-hoc analyses suggest that the difference was significant in men only (mean difference −7.3 (−11.8 to −2.6), p = 0.003). Sufentanil co-induction with propofol results in higher bispectral index values at loss of consciousness in elderly patients.
      PubDate: 2017-11-03T00:46:02.073707-05:
      DOI: 10.1111/anae.14102
  • Consequences of proceeding with surgery after resuscitation from
           intra-operative anaphylaxis
    • Authors: P. H. M. Sadleir; R. C. Clarke, B. Bozic, P. R. Platt
      Abstract: Intra-operative acute hypersensitivity reactions require a decision to be made regarding whether to proceed with or abandon the planned surgical procedure once the patient has stabilised. Using retrospective case controls, we examined all cases (223) of proven acute hypersensitivity reactions from 2005 to 2014 in Western Australia, in which the syndrome was recognised by the treating clinician before or during surgery, to determine whether recovery outcomes were adversely affected by proceeding with the planned procedure. Surgery proceeded in 104 patients (47%) and was abandoned in 119 (53%). The severity of acute hypersensitivity reactions was Société Française d'Anesthésie et de Réanimation grade 1 or 2 in 56 patients (25%), grade 3 in 128 (56%) and grade 4 in 39 (17%). Abandoning surgery was more common in patients with increasing severity of hypersensitivity. The rate of major hypersensitivity-related complications for all patients was zero for grade 1 and 2 reactions, 4.7% for grade 3 and 12.8% for grade 4. There were no deaths. Patients in whom surgery was completed were not observed to have a higher frequency of major hypersensitivity-related complications when compared with cases of similar severity in whom surgery was abandoned. For patients admitted to the intensive care unit, proceeding with surgery was not associated with an increased duration of mechanical ventilation of the lungs. Our results suggest that, once initial resuscitation has been achieved and if resuscitative efforts can be re-instituted if required, continuing with planned surgery in grade 1, 2 and 3 immediate hypersensitivity was not associated with poorer outcomes. After grade 3 reactions, there was a significant incidence of complications attributable to acute hypersensitivity regardless of whether surgery proceeded or was abandoned. Surgery was frequently abandoned in grade 4 immediate hypersensitivity and was associated with a high rate of complications.
      PubDate: 2017-11-02T06:56:05.809173-05:
      DOI: 10.1111/anae.14106
  • When rain stops play: a ‘Duckworth–Lewis method’ for surgical
           operating list productivity'
    • Authors: A. Tavare; J. J. Pandit
      PubDate: 2017-11-02T06:45:30.870255-05:
      DOI: 10.1111/anae.14120
  • Evaluation of a novel waste anaesthetic gas scavenger device for use
           during recovery from anaesthesia
    • Authors: R. Tallent; J. Corcoran, J. Sebastian
      Abstract: Volatile anaesthetic agents are a potential occupational health hazard to theatre and recovery staff. Operating theatres and anaesthetic rooms are required to be equipped with scavenging systems, but recovery units often are not. We compared exhaled, spectrophotometric sevoflurane and desflurane concentrations 15 cm from the mouth (‘patient breathing zone’) and 91 cm laterally to the patient (‘nurse work zone’) in 120 patients after tracheal extubation who were consecutively allocated to either ISO-Gard mask oxygen/scavenging or standard oxygen mask, 0 min, 10 min and 20 min after arrival in the theatre recovery unit. Median (IQR [range]) duration of anaesthesia was similar between groups (control 76 (44–119 [15–484]) min vs. study group 90 (64–130 [15–390]) min, p = 0.136). Using the ISO-Gard mask, the 20-min mean patient breathing zone and nurse work zone exhaled anaesthetic levels were ~ 90% and 78% lower than those recorded in the control group, respectively, and were within the recommended 2 ppm maximum environmental exposure limit in the patient breathing zone of 53 out of 60 (88%) and the nurse work zone of all 60 (100%) patients on first measurement in the recovery room (vs. 10 out of 60 (17%) and 40 out of 60 (67%) in the control group). Our study indicates that the ISO-Gard oxygen/scavenging mask reduces the level of exhaled sevoflurane and desflurane below recommended maximum exposure limits near> 85% of extubated patients within ~ 20 s of application in the recovery unit after surgery. We encourage the use of this mask to minimise the occupational exposure of recovery staff to exhaled volatile agents.
      PubDate: 2017-11-02T05:52:01.944149-05:
      DOI: 10.1111/anae.14100
  • Human cadavers preserved using Thiel's method for the teaching of
           fibreoptically-guided intubation of the trachea: a laboratory
    • Authors: C. J. László; Z. Szűcs, Á. Nemeskéri, G. Baksa, A. Szuák, M. Varga, E. Tassonyi
      Abstract: We assessed the suitability of human cadavers preserved using Thiel's method for teaching flexible fibreoptic tracheal intubation. Thirty-one anaesthetists unacquainted with this technique received didactic teaching followed by handling of the fibrescope on the Oxford teaching box. They then carried out fibreoptic intubations in two cadavers to establish a baseline sample of their intubation skills. Thereafter, we randomly assigned the trainees to two groups to practice fibreoptic intubation either on two distinct cadavers or on two airway manikins. After 7 days we re-assessed procedural skills using the same cadavers as at baseline. Intubation time was the primary outcome and secondary outcomes included the incidence of failed intubations. We also evaluated trainee satisfaction. The mean (SD) intubation time decreased from a baseline value of 74 (20) s to 35 (6) s in the cadaver group and to 56 (16) s in the manikin group. The effect of ‘time’ was significant (p = 0.002), indicating that both methods of training led to improvements. The training effect of the cadaveric method was greater than with the manikin method (p = 0.0016). Thirty-four failed intubations occurred at baseline vs. eight at the end of study (RR 0.24, 95%CI 0.11–0.51, p = 0.0002, NNT 9.6); six in the cadaver group and two in the manikin group (p = 0.22). We conclude that human cadavers preserved using Thiel's method are potentially better for teaching flexible fibreoptic tracheal intubation compared with manikins.
      PubDate: 2017-11-01T07:00:25.401883-05:
      DOI: 10.1111/anae.14104
  • Learning from the Law. A review of 21 years of litigation for pain
           during caesarean section
    • Authors: K. McCombe; D. G. Bogod
      Abstract: The large majority of caesarean sections in the UK are now carried out under neuraxial anaesthesia. Although this technique is widely accepted as being the safest option in most circumstances, the use of regional anaesthesia increases the risk of patients experiencing intra-operative discomfort or pain. Pain during operative obstetric delivery is the commonest successful negligence claim relating to regional anaesthesia against obstetric anaesthetists in the UK. In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning pain during caesarean section and consider how anaesthetists might avoid litigation.
      PubDate: 2017-11-01T07:00:20.343255-05:
      DOI: 10.1111/anae.14119
  • Management of hypotension with vasopressors at caesarean section under
           spinal anaesthesia – have we found the Holy Grail of obstetric
    • Authors: J. P. Campbell; G. M. Stocks
      PubDate: 2017-11-01T05:30:27.275448-05:
      DOI: 10.1111/anae.14114
  • International consensus statement on the management of hypotension with
           vasopressors during caesarean section under spinal anaesthesia
    • Authors: S. M. Kinsella; B. Carvalho, R. A. Dyer, R. Fernando, N. McDonnell, F. J. Mercier, A. Palanisamy, A. T. H. Sia, M. Van de Velde, A. Vercueil
      PubDate: 2017-11-01T05:25:25.886858-05:
      DOI: 10.1111/anae.14080
  • Maternal cardiac output response to colloid preload and vasopressor
           therapy during spinal anaesthesia for caesarean section in patients with
           severe pre-eclampsia: a randomised, controlled trial
    • Authors: R. A. Dyer; A. Daniels, A. Vorster, A. Emmanuel, M. J. Arcache, S. Schulein, A. R. Reed, C. J. Lombard, M. F. James, D. Dyk
      Abstract: We examined the haemodynamic effects of colloid preload, and phenylephrine and ephedrine administered for spinal hypotension, during caesarean section in 42 women with severe early onset pre-eclampsia. Twenty patients with pre-delivery spinal hypotension were randomly allocated to receive an initial dose of either 50 μg phenylephrine or 7.5 mg ephedrine; the primary outcome was percentage change in cardiac index. After a 300-ml colloid preload, mean (SD) cardiac index increased from 4.9 (1.1) to 5.6 (1.2) l.min−1.m−2 (p < 0.01), resulting from an increase in both heart rate, from 81.3 (17.2) to 86.3 (16.5) beats.min−1 (p = 0.2), and stroke volume, from 111.8 (19.0) to 119.8 (17.9) ml (p = 0.049). Fourteen (33%) and 23 (54.8%) patients exhibited a stroke volume response> 10% and> 5%, respectively; a significant negative correlation was found between heart rate and stroke volume changes. Spinal hypotension in 20 patients was associated with an increase from baseline in cardiac index of 0.6 l.min−1.m−2 (mean difference 11.5%; p < 0.0001). After a median [range] dose of 50 [50–150] μg phenylephrine or 15 [7.5–37.5] mg ephedrine, the percentage change in cardiac index during the measurement period of 150 s was greater, and negative, in patients receiving phenylephrine vs. ephedrine, at −12.0 (7.3)% vs. 2.6 (6.0)%, respectively (p = 0.0001). The percentage change in heart rate after vasopressor was higher in patients receiving phenylephrine, at −9.1 (3.4)% vs. 5.3 (12.6)% (p = 0.0027), as was the change in systemic vascular resistance, at 22.3 (7.5) vs. −1.9 (10.5)% (p < 0.0001). Phenylephrine effectively reverses spinal anaesthesia-induced haemodynamic changes in severe pre-eclampsia, if left ventricular systolic function is preserved.
      PubDate: 2017-10-31T06:05:28.043115-05:
      DOI: 10.1111/anae.14040
  • Is unconsciousness simply the reverse of consciousness'
    • Authors: F. Engbers
      PubDate: 2017-10-23T00:30:57.083519-05:
      DOI: 10.1111/anae.14121
  • Peripheral nerve block in ankle fracture surgery: a qualitative study of
           patients’ experiences
    • Authors: M. J. Henningsen; R. Sort, A. M. Møller, S. F. Herling
      Abstract: Peripheral nerve blocks are popular as a mode of anaesthesia for limb surgery and their beneficial effects are well documented in elective surgery. However, concerns have been raised about potential rebound pain outweighing the benefits in acute ankle fracture surgery. Furthermore, pain scores and morphine consumption do not provide a full picture, as pain is subjective. To evaluate the clinical usefulness of peripheral nerve blocks, we explored patients’ expectations and experiences by means of semi-structured interviews analysed with systematic text condensation. We obtained ethical approval and informed consent and sampled purposively among adult patients scheduled for ankle surgery with nerve blocks as the primary mode of anaesthesia. Patients were interviewed within 48 h postoperatively. Data saturation was reached after 13 interviews. We found that, despite pre-emptive ibuprofen and paracetamol, some patients did experience excruciating rebound pain for up to 2 h, although most had little or no pain. The patients had doubts about what to do when the block wore off, which led to a risk of unnecessary pain levels or morphine overuse. Patients had difficulty understanding the effect and course of the nerve blocks. They had misunderstandings regarding the blocks’ effect on sensation, resulting in fear of feeling pain during surgery and of permanent nerve damage after surgery. However, patients valued the mental alertness, ability to ambulate and efficient pain relief provided by the blocks. We recommend that patients be given thorough and repeated information as we feel this is crucial in preventing undesirable responses from patients, and is likely to increase the overall clinical usefulness of nerve blocks in acute limb surgery.
      PubDate: 2017-10-19T23:20:20.365866-05:
      DOI: 10.1111/anae.14088
  • Hyperbaric vs. isobaric bupivacaine for spinal anaesthesia for elective
           caesarean section: a Cochrane systematic review
    • Authors: B. L. Sng; N. L. R. Han, W. L. Leong, R. Sultana, F. J. Siddiqui, P. N. Assam, E. S. Chan, K. H. Tan, A. T. Sia
      Abstract: Both isobaric and hyperbaric bupivacaine have been used for spinal anaesthesia for elective caesarean section, but it is not clear if one is better than the other. The primary objective of this systematic review was to determine the effectiveness and safety of hyperbaric bupivacaine compared with isobaric bupivacaine administered during spinal anaesthesia for elective caesarean section. We included 10 studies with 614 subjects in the analysis. There was no evidence of differences either in the risk of conversion to general anaesthesia, with a relative risk (95%CI) of 0.33 (0.09–1.17) (very low quality of evidence), or in the need for supplemental analgesia, the relative risk (95%CI) being 0.61 (0.26–1.41) (very low quality of evidence). There was also no evidence of a difference in the use of ephedrine, the amount of ephedrine used, nausea and vomiting, or headache. Hyperbaric bupivacaine took less time to reach a sensory block height of T4, with a mean difference (95%CI) of −1.06 min (−1.80 to −0.31). Due to the rarity of some outcomes, dose variability, use of adjuvant drugs and spinal technique used, future clinical trials should look into using adequate sample size to investigate the primary outcome of the need for supplemental analgesia.
      PubDate: 2017-10-17T01:55:42.771013-05:
      DOI: 10.1111/anae.14084
  • Publisher's Note
    • PubDate: 2017-10-16T03:46:29.535951-05:
      DOI: 10.1111/anae.14117
  • Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and
           accidental awareness in surgical patients: an abridged Cochrane systematic
    • Authors: J. Hounsome; J. Greenhalgh, O. J. Schofield-Robinson, S. R. Lewis, T. M. Cook, A. F. Smith
      Abstract: Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is ‘explicit’ if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
      PubDate: 2017-10-16T02:25:35.412489-05:
      DOI: 10.1111/anae.14065
  • Can point-of-care ultrasound predict spinal hypotension during caesarean
           section' A prospective observational study
    • Authors: L. Zieleskiewicz; A. Noel, G. Duclos, M. Haddam, A. Delmas, C. Bechis, A. Loundou, J. Blanc, A. Mignon, L. Bouvet, S. Einav, A. Bourgoin, M. Leone
      Abstract: Spinal anaesthesia for elective caesarean section is associated with maternal hypotension, secondary to alteration of sympathetic tone and hypovolemia, in up to 70% of cases. Measurement of the subaortic variation in the velocity time integral (VTI) after passive leg raising allows prediction of fluid responsiveness. Our objective, in this prospective single-centre observational study, was to assess the ability of change in VTI after 45° passive leg raising to predict hypotension after spinal anaesthesia. Ultrasound measurements were performed just before elective caesarean section. Anaesthesia, intravenous coloading and prophylactic vasopressor treatment were standardised according to current guidelines. We studied 40 women. Hypotension occurred in 17 (45%) women. The area (95%CI) under the receiver operating characteristics (ROC) curve for the prediction of spinal hypotension was 0.8 (0.6–0.9; p = 0.0001). Seventeen women had a change in VTI with leg elevation ≤ 8%, which was predictive for not developing hypotension, and 11 had a change ≥ 21%, predictive for hypotension. The grey zone between 8% and 21%, with inconclusive values, included 12 women. We suggest that cardiac ultrasound provides characterisation of the risk of hypotension following spinal anaesthesia at elective caesarean section, and therefore may allow individualised strategies for prevention and management.
      PubDate: 2017-10-07T01:20:36.794559-05:
      DOI: 10.1111/anae.14063
  • ‘Your lack of planning does not constitute my emergency’ – caring
           for obstetric patients with mental illness
    • Authors: K. McCombe
      PubDate: 2017-10-05T23:25:20.650529-05:
      DOI: 10.1111/anae.14098
  • Restrictive or responsive' Outcome classification and unplanned
           sub-group analyses in meta-analyses
    • Authors: M. Heesen; M. Klimek, S. E. Hoeks
      PubDate: 2017-10-04T01:15:20.811598-05:
      DOI: 10.1111/anae.14078
  • Continuous infusion vs. intermittent bolus injection of furosemide in
           acute decompensated heart failure: systematic review and meta-analysis of
           randomised controlled trials
    • Authors: K. T. Ng; J. L. L. Yap
      Abstract: Loop diuretics remain a fundamental pharmacological therapy to remove excess fluid and improve symptom control in acute decompensated heart failure. Several recent randomised controlled trials have examined the clinical benefit of continuous vs. bolus furosemide in acute decompensated heart failure, but have reported conflicting findings. The aim of this review was to compare the effects of continuous and bolus furosemide with regard to mortality, length of hospital stay and its efficacy profile in acute decompensated heart failure. All parallel-arm randomised controlled trials from MEDLINE, EMBASE, PubMed and the Cochrane Database of Systematic Reviews from inception until May 2017 were included. Cross-over randomised controlled trials, observational studies, case reports, case series and non-systematic reviews that involved children were excluded. Eight trials (n = 669) were eligible for inclusion. There was no difference between furosemide continuous infusion and bolus administration for all-cause mortality (four studies; n = 491; I2 = 0%; OR 1.65; 95%CI 0.93–2.91; p = 0.08) or duration of hospitalisation (six studies; n = 576; I2 = 71%; mean difference 0.27; 95%CI −1.35 to 1.89 days; p = 0.74). Continuous infusion of intravenous furosemide was associated with increased weight reduction (five studies; n = 516; I2 = 0%; mean difference 0.70; 95%CI 0.12–1.28 kg; p = 0.02); increased total urine output in 24 h (four studies; n = 390; I2 = 33%; mean difference 461.5; 95%CI 133.7–789.4 ml; p < 0.01); and reduced brain natriuretic peptide (two studies; n = 390; I2 = 0%; mean difference 399.5; 95%CI 152.7–646.3 ng.l−1; p < 0.01), compared with the bolus group. There was no difference in the incidence of raised creatinine and hypokalaemia between the two groups. In summary, there was no difference between continuous infusion and bolus of furosemide for all-cause mortality, length of hospital stay and electrolyte disturbance, but continuous infusion was superior to bolus administration with regard to diuretic effect and reduction in brain natriuretic peptide.
      PubDate: 2017-09-22T02:35:25.704274-05:
      DOI: 10.1111/anae.14038
  • Real-time continuous monitoring of injection pressure at the needle tip
           for peripheral nerve blocks: description of a new method
    • Authors: C. Quadri; A. Saporito, X. Capdevila
      Abstract: The measurement of injection pressure during the performance of peripheral nerve blocks can be pivotal to detect intraneural placement of the needle tip and thus avoid intrafascicular injection. However, injection pressure can only be measured along the injection line (tubing), which is influenced by several factors. The primary aim of this feasibility study was to describe and validate the principle of a novel nerve-block needle conceived for real-time continuous monitoring of injection pressures at the needle tip. Our secondary aim was to provide measurements and compare injection pressure values at the needle tip and in the injection line. Four porcine lower limb anatomic models were prepared and extraneural injections were performed with fractioned boluses of 2 ml saline at a controlled infusion rate of 10 ml.min−1 (0.16 ml.s−1). Injection pressure at the needle tip was monitored and compared with the pressure in the injection line. The system proved to be reliable. Thirty injections were successfully performed without technical failures. The mean (95%CI) difference between pressures at the needle tip and the injection line varied substantially from 14.33 (12.58–16.08) kPa at 0.5 ml injected volume to 41.56 (39.66–43.45) kPa at the end of the injection. This study demonstrates that the described system allows for real-time continuous monitoring of injection pressure at the needle tip. Moreover, this study shows that injection pressure values measured in the injection line cannot be assumed to be a reliable indicator of the injection pressure at the needle tip.
      PubDate: 2017-09-14T23:46:29.283773-05:
      DOI: 10.1111/anae.14041
  • Evidence of hysteresis in propofol pharmacodynamics
    • Authors: P. O. Sepúlveda; E. Carrasco, L. F. Tapia, M. Ramos, F. Cruz, P. Conget, Q. F. B. Olivares, I. Cortínez
      Abstract: It is commonly assumed that loss of responsiveness and recovery of responsiveness occur at similar concentrations of propofol. However, the ‘conscious’ and ‘anaesthetised’ conditions produced by general anaesthetics may behave as two bistable states. We hypothesised that loss of responsiveness and recovery of responsiveness occur at different propofol concentrations. Propofol was administered to 19 healthy volunteers by effect-site target-controlled infusion using increasing and decreasing stable concentration steps of 7 min. Propofol serum concentrations were measured from venous blood samples at the end of each 7-min step. A long step of 14 min was performed at loss of responsiveness. At this step, propofol concentrations were measured at 7 and 14 min. Propofol concentrations measured at loss of responsiveness and recovery of responsiveness were 2.6 (1.2–4.7) μ−1 and 1.6 (0.6–3.3) μ−1, respectively (p < 0.001). Propofol plasma concentration and the corresponding bispectral index values measured at minute 7 and minute 14 of the long step performed at loss of responsiveness were 2.6 (1.2–4.7) vs. 2.6 (1.3–4.3) at recovery of responsiveness, (p = 0.96) and 61.2 (49.0–77.0) vs. 58.4 (45.0–74.0), (p = 0.058), respectively. Loss of responsiveness and recovery of responsiveness appear to occur at different propofol concentrations. However, it is possible that, if equilibration was not achieved between plasma and effect-sites at the end of each 7-min step, the higher concentrations found at loss of responsiveness compared with those observed during recovery of responsiveness could be explained by a possible bias in estimations of the effect-site concentrations of propofol by the Schnider model, rather than neural inertia.
      PubDate: 2017-09-05T04:55:36.720683-05:
      DOI: 10.1111/anae.14009
  • The view from the top. Is it worth recording for posterity'
    • Authors: B. J. Jenkins
      PubDate: 2017-08-22T01:35:26.150333-05:
      DOI: 10.1111/anae.14028
  • The illusion of informed consent
    • Authors: N. Chrimes; S. D. Marshall
      PubDate: 2017-07-26T00:10:22.846258-05:
      DOI: 10.1111/anae.14002
  • Issue Information – Editorial Board
    • Pages: 1 - 1
      PubDate: 2017-12-05T23:37:01.806398-05:
      DOI: 10.1111/anae.14066
  • Strategies for the prevention of airway complications – a narrative
    • Authors: T. M. Cook
      Pages: 93 - 111
      Abstract: Despite being infrequent, complications of airway management remain an important contributor to morbidity and mortality during anaesthesia and care of the critically ill. Developments in the last three decades have made anaesthesia safer, and this has been mirrored in the equipment and techniques available for airway management. Modern technology including novel oxygenation modalities, widespread availability of capnography, second-generation supraglottic airway devices and videolaryngoscopy provide the tools to make airway management safer still. However, technology will only take safety so far, and non-technical aspects of airway management are critically important for communication and decision making during airway crises, acknowledging a ‘cannot intubate, cannot oxygenate’ situation and transitioning to emergency front of neck airway. Randomised controlled trials provide little useful information about safety in this setting, and data from registries and databases are likely to be of more value. This narrative review focuses on recent evidence in this area.
      PubDate: 2017-12-05T23:36:59.398321-05:
      DOI: 10.1111/anae.14123
  • Accidental awareness during general anaesthesia – a narrative review
    • Authors: S. R. Tasbihgou; M. F. Vogels, A. R. Absalom
      Pages: 112 - 122
      Abstract: Unintended accidental awareness during general anaesthesia represents failure of successful anaesthesia, and so has been the subject of numerous studies during the past decades. As return to consciousness is both difficult to describe and identify, the reported incidence rates vary widely. Similarly, a wide range of techniques have been employed to identify cases of accidental awareness. Studies which have used the isolated forearm technique to identify responsiveness to command during intended anaesthesia have shown remarkably high incidences of awareness. For example, the ConsCIOUS-1 study showed an incidence of responsiveness around the time of laryngoscopy of 1:25. On the other hand, the 5th Royal College of Anaesthetists National Audit Project, which reported the largest ever cohort of patients who had experienced accidental awareness, used a system to identify patients who spontaneously self-reported accidental awareness. In this latter study, the incidence of accidental awareness was 1:19,600. In the recently published SNAP-1 observational study, in which structured postoperative interviews were performed, the incidence was 1:800. In almost all reported cases of intra-operative responsiveness, there was no subsequent explicit recall of intra-operative events. To date, there is no evidence that this occurrence has any psychological consequences. Among patients who experience accidental awareness and can later remember details of their experience, the consequences are better known. In particular, when awareness occurs in a patient who has been given neuromuscular blocking agents, it may result in serious sequelae such as symptoms of post-traumatic stress disorder and a permanent aversion to surgery and anaesthesia, and is feared by patients and anaesthetists. In this article, the published literature on the incidence, consequences and management of accidental awareness under general anaesthesia with subsequent recall will be reviewed.
      PubDate: 2017-12-05T23:37:00.593368-05:
      DOI: 10.1111/anae.14124
  • A novel wheeze
    • Authors: E. Perritt; A. Dunlop
      Pages: 124 - 124
      PubDate: 2017-12-05T23:37:02.283304-05:
      DOI: 10.1111/anae.14149
  • Seeking and reporting apparent research misconduct: errors and integrity
    • Authors: E. D. Kharasch; T. T. Houle
      Pages: 125 - 126
      PubDate: 2017-12-05T23:37:00.484691-05:
      DOI: 10.1111/anae.14147
  • Seeking and reporting apparent research misconduct: errors and integrity
           – a reply
    • Authors: J. B. Carlisle
      Pages: 126 - 128
      PubDate: 2017-12-05T23:37:00.269513-05:
      DOI: 10.1111/anae.14148
  • Seeking and reporting apparent research misconduct: errors and integrity
           – a reply
    • Authors: J. A. Loadsman; T. J. McCulloch
      Pages: 128 - 129
      PubDate: 2017-12-05T23:37:01.883913-05:
      DOI: 10.1111/anae.14170
  • Medical gas cylinder expiry dates – a reply
    • Authors: M. Nathanson
      Pages: 129 - 130
      PubDate: 2017-12-05T23:37:00.444493-05:
      DOI: 10.1111/anae.14154
  • Medical gas cylinder expiry dates
    • Authors: A. B. Philip; M. O'Sullivan, S. Mannion
      Pages: 129 - 129
      PubDate: 2017-12-05T23:36:58.053961-05:
      DOI: 10.1111/anae.14153
  • Patient emergence – statistical questions: a reply
    • Authors: J. H. Seo
      Pages: 130 - 130
      PubDate: 2017-12-05T23:37:03.010768-05:
      DOI: 10.1111/anae.14175
  • Patient emergence – statistical questions
    • Authors: G. Wong
      Pages: 130 - 130
      PubDate: 2017-12-05T23:37:00.374583-05:
      DOI: 10.1111/anae.14169
  • Coding for anaesthetic and peri-operative practice
    • Authors: A. Norton
      Pages: 130 - 132
      PubDate: 2017-12-05T23:36:57.89556-05:0
      DOI: 10.1111/anae.14171
  • Moderate vs. deep neuromuscular blockade and monitoring
    • Authors: P. Raju; G. Rodney
      Pages: 132 - 133
      PubDate: 2017-12-05T23:37:02.337221-05:
      DOI: 10.1111/anae.14172
  • Sugammadex advice for women of childbearing age
    • Authors: R. Williams; H. Bryant
      Pages: 133 - 134
      PubDate: 2017-12-05T23:37:01.548802-05:
      DOI: 10.1111/anae.14176
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