SummaryAll admissions into a six-bedded intensive care unit were audited prospectively over a 2-month period. Data were collected daily and classified according to criteria for intensive care or highdependency admission. There were 30 planned admissions (72 bed days) following elective major surgery, seven admissions following semi-elective surgery (41 bed days) and 47 emergency admissions (185 bed days). Overall bed occupancy was 89%. Of 366 possible intensive care days, 66 (23%) were occupied by high-dependency patients. Of the planned admissions all but five were discharged within 2 days. There were 39 major complications during the study period requiring life-saving interventions and 16 lesser but significant complications. In 12% of patients discharge was delayed because of the absence of a high-dependency unit. Four patients were transferred to an intensive care unit in another hospital and four patients were discharged prematurely because other patients required urgent admission. Seven patients were refused admission and three patients scheduled for elective operations had their surgery deferred. We estimate that over the study period 22 additional patients could have been cared for if a high-dependency unit existed. The suggestion that high-dependency units will solve some of the shortages created by lack of intensive care beds [1][2][3] is unproven. It appears that high-dependency provision significantly reduces the rate of cancellation of major elective surgery [4] and one report suggests a 13% reduction in mortality in the year following its introduction [5]. A high-dependency unit also provides a useful intermediate facility where more complex therapy and monitoring can be provided safely and efficiently [6]. KeywordsWe audited all admissions to our general intensive care unit prospectively over a 2-month period to estimate demand for high-dependency care. MethodThe type of patient (intensive care or high dependency) was recorded daily according to the criteria for admission described by (Appendix). Every patient occupying an intensive care unit (ICU) bed was evaluated at 10 a.m. each day over a 2-month period and classified as requiring an ICU or high-dependency unit (HDU) bed. Although the unit has six beds it was possible to admit more patients than there were beds due to transfers or deaths in the preceding 24-h period. The data collected daily included the patient's name, age, sex, diagnosis, operation (where relevant), complications in the last 24 h, length of stay and ICU outcome. Hospital outcome was determined after completion of the study. We also collected details on the number of ICU transfers in and out of the unit, elective surgical cancellations, refusals for admission to ICU and requests for admission to HDU. FacilitiesThe hospital has a six-bed general ICU which forms the basis for this study. There is also a three-bed liver HDU, a six-bed thoracic HDU, a nine-bed cardiac adult ICU and a six-bed cardiac HDU; these units are not under our direct ResultsThere were 84 admissions in th...
SummaryObstructive sleep apnoea syndrome in children is a complex disorder characterised by repeated nocturnal episodes of increased upper airway resistive load. It is most commonly associated with adenotonsillar hypertrophy and more children are now presenting for adenotonsillectomy. These children may pose different anaesthetic problems to those having surgery for recurrent infection alone and anaesthetic morbidity and mortality has been reported. In addition, due to the varied symptomatology of the condition, children with unrecognised obstructive sleep apnoea syndrome may present for incidental surgery. This is of importance as patients with undiagnosed obstructive sleep apnoea syndrome may experience additional peri-operative morbidity when undergoing incidental surgery. This article aims to review the aetiology, pathophysiology, clinical presentation and anaesthetic management of children with obstructive sleep apnoea syndrome.
by some authors that the tip of the cannula should be withdrawn outside the lumen of the vein and sited subcutaneously to avoid the rare complication of air embolism. 4 It has also been suggested that this method will protect the catheter from kinking. The circumstances of this case challenge that assumption, and suggest that it may be preferable to leave the cannula inside the vein during catheter insertion. Knotting of a PICC is a potential complication which one must consider whenever there is difficulty in advancing the catheter, or when there is difficulty in removing the stylet. When this complication is suspected, the course of the catheter should be confirmed radiologically, and the catheter removed surgically, as excessive traction on the catheter could lead to further complications.
INTRODUCTION Opioid sparing in postoperative pain management appears key in colorectal enhanced recovery. Transversus abdominis plane (TAP) blocks offer such an effect. This study aimed to quantify this effect on pain, opioid use and recovery of bowel function after laparoscopic high anterior resection. METHODS This was a retrospective analysis of prospective data on 68 patients. Patients received an epidural (n=24), intravenous morphine patient controlled analgesia (PCA, n=22) or TAP blocks plus PCA (n=22) determined by anaesthetist preference. Outcome measures were numerical pain scores (0-3), cumulative intravenous morphine dose and time to recovery of bowel function (passage of flatus or stool). RESULTS There were no differences in patient characteristics, complications or extraction site. The TAP block group had lower pain scores (0.7 vs 1.36, p<0.001) and morphine requirements (8mg vs 15mg, p=0.01) than the group receiving PCA alone at 12 hours and 24 hours. Earlier passage of flatus (2.0 vs 2.7 vs 3.4 days, p=0.002), stool (3.1 vs 4.1 vs 5.5 days, p=0.04) and earlier discharge (4 vs 5 vs 6 days, p=0.02) were also seen. CONCLUSIONS Use of TAP blocks was found to reduce pain and morphine use compared with PCA, expedite recovery of bowel function compared with PCA and epidural, and expedite hospital discharge compared with epidural.
SummaryThree different concentrations of bupivacaine, 0.125%, 0.062% and 0.031 %, all with diamorphine 0.0025%, were given as an epidural infusion at 10 m1.h-' to 63 mothers in labour. When the three infusions were compared, significant differences were found in maternal requirements for top-ups and the degree of motor block, but there were no dixerences in the pain scores. The reduced motor block was not associated with a reduction in the instrumental delivery rate. Key wordsAnaesthetic techniques, regional; epidural. Analgesics; diamorphine. Anaesthetics, local; bupivacaine. Anaesthesia; obstetric.The use of continuous epidural infusions for analgesia during labour has increased in popularity. This is based on the hypothesis that infusions will provide superior analgesia when compared to intermittent injections [l, 21. Epidural infusions have been in use in this department for the past 4 years and have been the subject of two previous studies [3,4]. In the first infusion study [3] it was found that a bupivacaine/diamorphine mixture produced a significant reduction in pain scores compared to a bupivacaine/fentanyl mixture or the 0.125% solution of bupivacaine alone. The second study [4] compared three solutions with 0.0002% fentanyl added to 0.125%, 0.062% and 0.031 YO bupivacaine.Despite the use of these dilute bupivacaine solutions we were unable to detect any difference in the number of top-ups required, the degree of motor block or the instrumental delivery rate. A recent study has suggested that fentanyl may augment the neural blockade produced by local anaesthetics and so enhance both the sensory and, importantly, the motor block [5].In the light of the above findings we decided to repeat the second study replacing fentanyl with diamorphine, in the concentration used in the first study, in the three different concentrations of bupivacaine. MethodsThe study was approved by the district ethics committee and written consent was obtained from all participants. Healthy primiparous mothers with uncomplicated singleton pregnancies were included in the study, provided they had not received systemic opioids and were expected to continue in labour for at least 3h.A baseline pain score was measured at the peak of a contraction using a 200mm visual analogue score. All mothers were given 1OOOml of compound sodium lactate solution intravenously. The epidural catheter was inserted 3 cm into the epidural space at either the second or third lumbar interspace. A test dose of 3 ml of 0.5% bupivacaine followed by a further 5 ml was used to establish analgesia.At 30 min we repeated the pain score and assessed the upper level of the sensory block to cold, using an ice cube and the motor block in both legs using the Bromage scale [6]. If satisfactory analgesia was not obtained then the mother was removed from the study.Mothers were then randomly allocated to receive one of three dilutions of bupivacaine, all of which contained 0.025 mg.ml-I of diamorphine. group A received 0.125%, group B 0.062% and group C 0.031% bupivacaine....
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