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Critical Care

This category contains 18 posts

Regional or General Anaesthhesia for Hip Fracture

A 78 year old female patient is brought to the operating room with a fractured hip. She tells you that she wants to “go asleep” for the operation. How do you advise her? Two papers in July’s Anesthesiology have shed light on this issue. Both studies mine large databases and so care must be taken … Continue reading

Giving up Colloid? – Yes we can!

Colloid lovers are distraught by the publication of the 6S study from Scandanavia, which has demonstrated that hydroxy ethyl starches (HES) were associated with poor outcomes (read here). For many of us, however, colloids are like nicotine, caffeine, carbohydrates and heroin rolled into one: we just believe in them. It’s so hard to stop. This month … Continue reading

EuSOS study published – and it’s not pretty!

46,539 patients from all over Europe were recruited to the The European Surgical Outcomes Study over 7 days in April 2011 (read here). Day cases, cardiac and neurosurgical patients were excluded. The overall mortality rate was 4% (nearly 1 in 20 patients). 8% of patients were admitted to ICU or HDU at some stage – … Continue reading

Hydroxy Ethyl Starches – are we nearing the end of the road?

When the VISEP study was published in 2008,1 proponents of colloid based resuscitation (myself included) argued that, since the study was conducted using old generation pentastarches, the data were not generalizable to all hydroxyl-ethyl fluids.2 Indeed there was an emerging body of evidence supporting the safety of newer, lower molecular weight starches; particularly those composed … Continue reading

Flotrac-Vigileo – useful tool or toy?

The Flotrac-Vigileo system appears to have become the first line haemodynamic monitor in Galway. How did this happen, and is it just a toy? Over the past 2 decades there have been considerable advances in minimally invasive cardiovascular monitoring. This results from a greater acceptance of the flow-model approach to fluid resuscitation,1 a cultural shift … Continue reading

NAP4 report on airway catastrophes

Have you had a highly challenging airway situation in the ICU or the emergency department?  Did it lead to a major adverse event?  If so you are not alone, as the NAP4 report demonstrates: http://www.rcoa.ac.uk/index.asp?PageID=1089 Although there is no denominator, and a direct comparison with operating theatre events was not a purpose of the report, … Continue reading

Acute Respiratory Distress in the Recovery Room (tutorial)

Clinical Scenario: A 57 year old male undergoes upper abdominal surgery. He refused an epidural. The intraoperative course was uneventful. He was given 2mg hydromorphone in the OR. He was extubated, breathing 360 ml tidal volumes; arousable. Shortly after arrival to the recovery room, the patient develops acute respiratory distress. His respiratory rate increases to … Continue reading

Agitation and Pain in the Recovery Room (tutorial)

Problem: A 43 year old male returns from the operating room following cholecystectomy. The operation had been originally planned using the laparoscopic approach. However it became necessary to convert to an open procedure. Intraoperatively the patient received fentanyl 300mic/g, propofol, vecuronium, oxygen and desflurane and cefazolin. At the end of surgery, neuromuscular blockade (sustained tetanus … Continue reading

Common Questions Regarding Stewart Approach to Acid Base Chemistry

I receive a lot of emails from confused doctors regarding the modern (Stewart) approach to acid base chemistry. A common question relates to the relative quantity of hydrogen/hydronium and hydroxyl ions. For example, if chloride is dissolved in water there is a net increase in hydrogen and a net decrease in hydroxyl. Where does the … Continue reading