- Postoperative delirium in total knee and hip arthroplasty patients: a study of perioperative modifiable risk factors. [Journal Article]
- BJBr J Anaesth 2018; 120(5):999-1008
- CONCLUSIONS: In this cohort of hip and knee arthroplasty patients, anaesthesia type and perioperative medications were associated with increased odds for postoperative delirium. Our results support the notion that modifiable risk factors may exacerbate or attenuate risk for postoperative delirium.
- Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. [Review]
- BJBr J Anaesth 2018; 120(5):988-998
- Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injur...
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
- Reversal of dabigatran by intraosseous or intravenous idarucizumab in a porcine polytrauma model. [Journal Article]
- BJBr J Anaesth 2018; 120(5):978-987
- CONCLUSIONS: Intravenous and intraosseous idarucizumab were comparable for reversing dabigatran in a porcine trauma model. Dabigatran reversal could be monitored using fully automated thromboelastography.
- Dexmedetomidine metabolic clearance is not affected by fat mass in obese patients. [Journal Article]
- BJBr J Anaesth 2018; 120(5):969-977
- CONCLUSIONS: We did not find a negative influence of obesity in dexmedetomidine clearance when doses were adjusted to lean body weight. Liver blood flow showed a significant effect on dexmedetomidine clearance.
- Pharmacokinetic and pharmacodynamic study of intranasal and intravenous dexmedetomidine. [Journal Article]
- BJBr J Anaesth 2018; 120(5):960-968
- CONCLUSIONS: There is no difference in bioavailability with atomisation or nasal drops. A similar degree of sedation can be achieved by either method.
- Pharmacokinetic-pharmacodynamic model for propofol for broad application in anaesthesia and sedation. [Journal Article]
- BJBr J Anaesth 2018; 120(5):942-959
- CONCLUSIONS: We developed a PK-PD model to predict the propofol concentrations and BIS for broad, diverse population. This should be useful for TCI in anaesthesia and sedation.
- The fragility of statistically significant findings in randomised controlled anaesthesiology trials: systematic review of the medical literature. [Review]
- BJBr J Anaesth 2018; 120(5):935-941
- The fragility index (FI), the number of events the statistical significance a result depends on, and the number of patients lost to follow-up are important parameters for interpreting randomised clin...
The fragility index (FI), the number of events the statistical significance a result depends on, and the number of patients lost to follow-up are important parameters for interpreting randomised clinical trial results. We evaluated these two parameters in randomised controlled trials in anaesthesiology. For this, we performed a systematic search of the medical literature, seeking articles reporting on anaesthesiology trials with a statistically significant difference in the primary outcome and published in the top five general medicine journals, or the top 15 anaesthesiology journals. We restricted the analysis to trials reporting clinically important primary outcome measures. The search identified 139 articles, 35 published in general medicine journals and 104 in anaesthesiology journals. The median (inter-quartile range) sample size was 150 (70-300) patients. The FI was 4 (2-17) and 3 (2-7), and the number of patients lost to follow-up was 0 (0-18) and 0 (0-6) patients in trials published in general medicine and anaesthesiology journals, respectively. The number of patients lost to follow-up exceeded the FI in 41 and 27% in trials in general medicine journals and anaesthesiology journals, respectively. The FI positively correlated with sample size and number of primary outcome events, and negatively correlated with the reported P-values. The results of this systematic review suggest that statistically significant differences in randomised controlled anaesthesiology trials are regularly fragile, implying that the primary outcome status of patients lost to follow-up could possibly have changed the reported effect.
- Use of prothrombin complex concentrate for management of coagulopathy after cardiac surgery: a propensity score matched comparison to plasma. [Journal Article]
- BJBr J Anaesth 2018; 120(5):928-934
- CONCLUSIONS: Our exploratory study suggests that the use of PCCs as part of a multifaceted coagulation management strategy may have blood-sparing effects. Their incorporation into clinical practice, however, must await determination of their risk-benefit profile via multicentre randomised trials.
- Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. [Review]
- BJBr J Anaesth 2018; 120(5):914-927
- Neutralisation of systemic anticoagulation with heparin in cardiac surgery with cardiopulmonary bypass requires protamine administration. If adequately dosed, protamine neutralises heparin and reduce...
Neutralisation of systemic anticoagulation with heparin in cardiac surgery with cardiopulmonary bypass requires protamine administration. If adequately dosed, protamine neutralises heparin and reduces the risk of postoperative bleeding. However, as its anticoagulant properties are particularly exerted in the absence of heparin, overdosing of protamine may contribute to bleeding and increased transfusion requirements. This narrative review describes the mechanisms underlying the anticoagulant properties and side-effects of protamine, and the impact of protamine dosing on the activated clotting time and point-of-care viscoelastic test results, and explains the distinct protamine dosing strategies in relation to haemostatic activation and postoperative bleeding. The available evidence suggests that protamine dosing should not exceed a protamine-to-heparin ratio of 1:1. In particular, protamine-to-heparin dosing ratios >1 are associated with more postoperative 12 h blood loss. The optimal protamine-to-heparin ratio in cardiac surgery has, however, not yet been elaborated, and may vary between 0.6 and 1.0 based on the initial heparin dose.
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- Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis. [Review]
- BJBr J Anaesth 2018; 120(5):904-913
- CONCLUSIONS: The complication rate for CSF drainage is not negligible. Our results help define a more accurate risk-benefit ratio for CSF drain placement at the time of repair of thoracic and thoraco-abdominal aneurysms.