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British Journal of Anaesthesia - current issue

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  1. Bone cement implantation syndrome in cemented hemiarthroplasty for femoral neck fracture: incidence, risk factors, and effect on outcome
    Background

    Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and loss of consciousness occurring around the time of bone cementation. Using a recently proposed severity classification of BCIS, we estimated the incidence of and risk factors for BCIS and its impact on mortality in cemented hemiarthroplasty for femoral neck fractures.

    Methods

    In this retrospective study, 1016 patients undergoing cemented hemiarthroplasty were included. Medical history and medication were obtained from medical records. Anaesthesia charts for all patients were reviewed for mean arterial pressure, arterial oxygen saturation, and heart rate before, during, and after cementation. Each patient was classified as having no BCIS (grade 0) or BCIS grade 1, 2, or 3, depending on the degree of hypotension, arterial desaturation, or loss of consciousness around cementation.

    Results

    The incidence of BCIS grade 1, 2, and 3 were 21%, 5.1%, and 1.7%, respectively. Early mortality in BCIS grade 1 (9.3%) did not differ significantly from BCIS grade 0 (5.2%), while early mortality in BCIS grade 2 (35%) and grade 3 (88%) were significantly higher when compared with grades 0 and 1. Early mortality was also higher in BCIS grade 3 when compared with grade 2. Independent predictors for severe BCIS were: ASA grade III—IV, chronic obstructive pulmonary disease, and medication with diuretics or warfarin. Severe BCIS was associated with 16-fold increase in mortality.

    Conclusions

    BCIS is a commonly occurring phenomenon in cemented hemiarthroplasty and severe BCIS has a huge impact on early and late mortality.

  2. Association between fibromyalgia and adverse perioperative outcomes
    Background

    Fibromyalgia, the classic non-inflammatory pain syndrome, has been associated with chronic inflammatory makers which are linked with increased morbidity and mortality. We tested the primary hypothesis that patients with fibromyalgia undergoing hospital procedures have a high risk of cardiovascular complications. Our secondary goals were to evaluate the association of fibromyalgia with: (i) in-hospital thromboembolic events, (ii) in-hospital mortality, and (iii) in-hospital microvascular complications.

    Methods

    We obtained 21.78 million discharge records from 2009 to 2010 from the US Agency for Healthcare Research and Quality censuses across the seven states. We matched fibromyalgia records and compared records with controls based on age, gender, state of discharge, principal procedure, and a propensity score developed from the set of diagnosis-related predictors. A multivariable logistic regression was used to compare matched fibromyalgia patients and controls on the primary and secondary outcomes.

    Results

    We matched 89 589 pairs for a total sample size of 179 178 discharge records. The adjusted odds ratio for in-hospital cardiovascular complications was 1.04 [99% confidence interval (CI): 0.90–1.19, P=0.51], for thromboembolic events was 1.03 (99% CI: 0.93–1.15, P=0.46), for in-hospital mortality was 0.81 (99% CI: 0.73–0.89, P<0.001), and for microvascular complications was 0.96 (99% CI: 0.88, 1.04, P=0.18). Two separate sensitivity analyses produced results similar to that of the primary analysis for all three complication outcomes.

    Conclusions

    We found no evidence that the diagnosis of fibromyalgia increased the risk of in-hospital complications. Fibromyalgia seems to be associated with a reduction in in-hospital mortality, but this requires confirmation with a large prospective controlled study.

  3. Relationship between early postoperative C-reactive protein elevation and long-term postoperative major adverse cardiovascular and cerebral events in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study
  4. The College of Anaesthetists of Ireland: Delaney Medal Competition 2014: College of Anaesthetists of Ireland, Dublin, Ireland, March 6, 2014
  5. Ultrasound-Guided Nerve Blocks on DVD for PC, Upper Limbs and Lower Limbs
  6. Equipment in Anaesthesia and Critical Care: A Complete Guide for the FRCA
  7. Pain Comorbidities: Understanding and Treating the Complex Patient
  8. Oxygen 93: a new option for European hospitals
  9. Benefits and possible improvements of an anaesthesia information management system in a quality assurance programme
  10. B-type natriuretic peptide and echocardiographic indices of left ventricular filling in critically ill patients with severe sepsis: a cohort study
  11. GAL-021, a new intravenous BKCa-channel blocker, is well tolerated and stimulates ventilation in healthy volunteers
    Background

    Potassium-channels in the carotid body and the brainstem are important regulators of ventilation. The BKCa-channel contains response elements for CO, O2, and CO2. Its block increases carotid body signalling, phrenic nerve activity, and respiratory drive. GAL-021, a new BKCa-channel blocker, increases minute ventilation in rats and non-human primates. This study assessed the single-dose safety, tolerability, pharmacokinetics (PKs), and pharmacodynamics (PDs) of GAL-021 in healthy volunteers.

    Methods

    Thirty subjects participated in a nine-period, randomized, double-blinded, placebo-controlled, crossover, ascending dose, first-in-human study with i.v. infusions of 0.1–0.96 mg kg–1 h–1 for 1 h and intermediate doses up to 4 h.

    Results

    Adverse event rates were generally similar among dose levels and between placebo- and GAL-021-treated subjects. At higher GAL-021 doses, a mild/moderate burning sensation at the infusion site occurred during the infusion. No clinically significant changes in vital signs or clinical chemistries were noted. Minute ventilation increased (AUE0–1 h 16%, P<0.05) and end-tidal carbon dioxide ($${\mathrm{E}}_{\mathrm{C}{\mathrm{O}}_{2}}^{\mathrm{\prime }}$$) decreased (AUE0–1 h 6%, P<0.05) during the first hour at 0.96 mg kg–1 h–1 with 1/2-maximal $${\dot{V}}_{\mathrm{E}}$$ and $${\mathrm{E}}_{\mathrm{C}{\mathrm{O}}_{2}}^{\mathrm{\prime }}$$-change occurring by 7.5 min. Drug concentration rose rapidly during the infusion and decreased rapidly initially (distribution t1/2 of 30 min) and then more slowly (terminal t1/2 of 5.6 h).

    Conclusions

    GAL-021 was safe and generally well tolerated with adverse events comparable with placebo except for an infusion site burning sensation. GAL-021 stimulated ventilation at the highest doses suggesting that greater infusion rates may be required for maximum PD effects. GAL-021 had PK characteristics consistent with an acute care medication.

  12. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr of age
    Background

    Miller laryngoscope blades are preferred for laryngoscopy in infants and children <2 yr of age. Despite their long history, the laryngeal view with the Miller blade size 1 has never been compared with that with the Macintosh (MAC) blade in children. This prospective, single-blinded, randomized study was designed to compare the laryngeal views with the size 1 Miller and MAC blades in children <2 yr.

    Methods

    With IRB approval, 50 ASA I and II children <2 yr undergoing elective surgery were enrolled. After an inhalation induction and neuromuscular block with i.v. rocuronium 0.5 mg kg–1, two laryngeal views were obtained with a single blade (Miller or MAC) in each child: one lifting the epiglottis and another lifting the tongue base. The best laryngeal views in each blade position were photographed with a SONY® Cyber-shot camera and rated by a blinded anaesthesiologist using the percentage of glottic opening scale.

    Results

    The scores with the Miller blade lifting the epiglottis and the MAC blade lifting the tongue base were similar. The scores with the Miller blade lifting the epiglottis and the tongue base were similar. The scores for the MAC blade lifting the tongue base were greater than those lifting the epiglottis (95% confidence interval: 7.6–26.8) (P=0.0004).

    Conclusions

    In infants and children <2 yr of age, optimal laryngeal views may be obtained with either the Miller size 1 blade lifting the epiglottis or with the Miller or MAC blades lifting the tongue base.

    Clinical trial registration

    NCT01717872 at Clinical Trials.gov.

  13. Short-term changes of intraocular pressure after cervical interlaminar epidural injection: a pilot study
    Background

    Cervical epidural injection (CEI) is widely performed on patients with intervertebral disc herniation. The aim of the present study was to investigate the short-term effects of CEI on non-invasive intraocular pressure (IOP) measurements in subjects with normal eyes.

    Methods

    This prospective study enrolled 15 patients who were undergoing CEI at the C5/6 level with an interlaminar approach in the left lateral decubitus position. IOP was measured in both eyes by a rebound tonometer (Icare-PRO, Icare Finland Oy, Helsinki, Finland). A total volume of 14 ml (4 ml non-ionic contrast, a mixture of 0.2% lidocaine 1 ml and normal saline 4 ml for irrigation and a mixture of normal saline 4.5 ml with non-particulate betamethasone 2 mg) was injected with 1.0 ml s–1. IOP was measured 5 min after the lateral decubitus position (T0, baseline), immediately after CEI (T1), and 1 min intervals for 5 min (T2–T6).

    Results

    The values of left and right baseline IOP (T0) were 18.9 (2.0) and 15.6 (2.6) mm Hg, respectively. IOP of left and right eyes at T1 [26.6 (4.2) and 21.2 (2.5) mm Hg, respectively] and T2 [26.2 (4.5) and 21.0 (2.8) mm Hg, respectively] were significantly higher compared with T0. These values immediately decreased at T3 and returned to baseline levels within 5 min after CEI.

    Conclusions

    CEI resulted in an elevation of IOP of both eyes. However, the effects were transient only lasting a few minutes.

  14. Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block
    Background

    This study was designed to determine whether a 4 day perioperative regimen of gabapentin added to celecoxib improves in-hospital rehabilitation and physical function on postoperative day 4 and 6 weeks and 3 months after total knee arthroplasty (TKA).

    Methods

    After Research Ethics Board approval and informed consent, 212 patients were enrolled in a randomized, double-blinded, placebo-controlled study. Two hours before surgery, patients received celecoxib 400 mg p.o. and were randomly assigned to receive either gabapentin 600 mg or placebo p.o. Two hours later, patients received femoral, sciatic nerve blocks, and spinal anaesthesia. After operation, patients received gabapentin 200 mg or placebo three times per day (TID) for 4 days. All patients also received celecoxib 200 mg q12 h for 72 h and i.v. patient-controlled analgesia for 24 h. Pain and function were assessed at baseline, during hospitalization, on postoperative day 4 (POD4), and 6 weeks and 3 months after surgery.

    Results

    The gabapentin group used less morphine in the first 24 h after surgery [G=38.3 (29.5 mg), P=48.2 (29.4 mg)] (P<0.0125) and had increased knee range of motion compared with the placebo group in-hospital (P<0.05). There were no differences between groups in favour of the gabapentin group for pain or physical function on POD 4 [95% confidence interval (CI): pain: –1.4, 0.5; function: –6.3, 2.0], 6 weeks (95% CI: pain: 0.1, 1.9; function: –0.2, 6.5) or 3 months (95% CI: pain: –0.2, 1.7; function: –2.2, 4.3) after TKA.

    Conclusions

    In the context of celecoxib, spinal anaesthesia, femoral and sciatic nerve blocks, a dose of gabapentin 600 mg before operation followed by 4 days of gabapentin 200 mg TID decreased postoperative analgesic requirements and improved knee range of motion after TKA. Gabapentin provided no improvement in pain or physical function on POD4 and 6 weeks or 3 months after surgery.

  15. Platelet count and function in paediatric cardiac surgery: a prospective observational study
    Background

    Platelet deficiency, impaired platelet function, or both increase the risk of bleeding complications. We assessed platelet count and function during and after paediatric cardiac surgery. Secondary aims included the effect of modified ultrafiltration, identification of factors associated with platelet dysfunction, and to assess associations between platelet function and transfusion requirements.

    Methods

    Fifty-seven patients were included in a prospective observational study. Platelet count and platelet function (multiple-electrode impedance aggregometry) were analysed before and during cardiopulmonary bypass (CPB), after modified ultrafiltration, on arrival at the intensive care unit, and on the first postoperative day. Intraoperative transfusions of blood products were registered.

    Results

    Both platelet count and platelet aggregation were markedly reduced during surgery with the greatest reduction at the end of CPB. On postoperative day 1, platelet count was still reduced by 50%, while platelet aggregation had returned to—or above—preoperative levels. There were only moderate correlations between platelet count and platelet aggregation. Modified ultrafiltration had no significant influence on platelet count or aggregation. Young age, low weight, and long operation time were associated with poor platelet aggregation during surgery, while young age, low weight, high preoperative haemoglobin levels, and low preoperative platelet count were associated with poor aggregation after operation. Patients with impaired platelet function during CPB had markedly increased intraoperative transfusion requirements.

    Conclusions

    Platelet count and platelet aggregation are markedly reduced during and immediately after paediatric cardiac surgery, especially in neonates. The recovery in aggregation is faster than that in platelet count. Intraoperative platelet dysfunction is associated with increased transfusion requirements.