Civilian liver trauma is generally sustained by blunt injury, with management strategies increasingly focusing on selective non-operative strategies and endovascular intervention. Military liver trauma is more often ballistic in nature and almost always requiring operative intervention. This article reviews established and evolving surgical techniques in the operative management of liver trauma.
Introduction and ObjectivesParacetamol is globally the most frequently prescribed drug amongst infants being employed in a variety of different contexts – from acute febrile illnesses to postoperative analgesia. Prior epidemiological evidence had long inferred a correlation between paracetamol to the ontogeny and exacerbation of asthmatic symptoms, leading to some clinicians advocating for a total prohibition. In view of the evidence being primarily from cohort studies, uncertainty persisted about the strength of the evidence as concerns were raised about the validity of observational cohort studies to ascertain causation, particularly in the absence of a placebo or a control group.MethodsA systematic review of the medical literature search was performed from bibliographic databases that included: Pubmed/Medline, EMBASE, CINAHL, CENTRAL, and Google Scholar; from 1975 until June 2017, using a prospective and explicit search criteria. The Mantel Haenszel (MH) method using a random effects model calculated the weighted odd ratio (OR).Results256 studies were identified from abstracts and titles with 9 studies being included in this review: 7 were prospective cohorts studies and two RCTs. The study ascertained that paracetamol was not associated with increased risk of asthma symptoms: MH-OR 0.083 (95% CI 0.051–0.1332). However, the substantially high degree of heterogeneity (I2=99%) illustrated the limitations of combining the weighted MH-OR from cohort studies. Four prospective cohort studies reported a statically significant association between paracetamol and asthma symptoms, whereas a well conducted, rigorous, double blinded RCT found no significant difference. The potential mechanisms by which paracetamol induced bronchospasm has not been fully elucidated; however the depletion of glutathione in lung parenchyma, increased intra and extra-mitochondrial oxidative stress, and reactive oxygen species are all thought to have a contributory role.ConclusionsWhilst prior cohort studies had previously inferred causation between paracetamol and the exacerbations of asthma symptoms, a well conducted and rigorous RCT demonstrated no significant association. Notwithstanding the limitations of meta-analysis, we recommend that paracetamol remains safe, with usage being contextualised to follow current best practice paradigms. Reflectively, the review raises the caveat of the unquestioned advocacy of paracetamol or any drug as a cultural axiom.Abstract S61 Figure 1Summary of the included studies, a forest plot for random effects meta-analysis of odd ratios and summary of the risk of bias.
BackgroundAcute bronchospasm is common amongst mechanically ventilated patients, associated with significant morbidity and mortality and constitutes a substantial burden on already austerely limited resources. The three axial methods by which (non-intravenous) bronchodilators can be administered include nebulisers, metered dose inhalers (MDI) and more recently, direct endotracheal liquid boluses (ELB). Previous studies have failed to demonstrate the advantage of one mode of delivery versus the other and there are no systematic reviews directly comparing all three therapies.AimsThe study sought to ascertain the efficacy of nebulisers, MDI and ELB for the management of acute bronchospasm in adult, mechanically ventilated patients.MethodsBy means of a prospective protocol, a systematic review was undertaken to compare randomised controlled trials (RCTs) exploiting both the GRADE and Cochrane methodology. We intended to assess the quality and strength of the evidence, risk of bias, the magnitude of the effect size, and to meta-analyse the main outcome measures: peak inspiratory pressure – PIP and airway resistance – Raw.ResultsFive studies involving 73 patients were included in this review. Four studies (59-subjects) compared the efficacy of nebulisers against MDI, and one study (14-subjects) compared ELB against MDI. The review found that all three modes were effective in significantly reducing both PIP and Raw, with two studies suggesting that nebulisers appear to be more effective than MDI (GRADE – moderate). ELB was found to be especially effective as a rescue therapy when conventional management had failed (GRADE – moderate). The studies were limited by small sample sizes, large variability in outcomes measures, incomplete reporting and a high degree of heterogeneity; thus, precluding a meta-analysis. The risk of bias ranged from low to uncertain across most domains.ConclusionsA systematic review of RCTs found that there was insignificant evidence to assert the superiority of any one mode of bronchodilators over the other, and thus a balanced and nuanced approach to managing acute bronchospasm should be contextualised to the individual needs and best-interest of the patient using a multi-modal approach. Further high-quality RCTs with larger samples sizes, preferably comparing all three modalities are required to conclusively provide a tangible answer.
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