C.H.V. Duez

Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review

Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

Platelet aggregation during targeted temperature management after out-of-hospital cardiac arrest: A randomised clinical trial

Abstract Some studies conclude that mild hypothermia causes platelet dysfunction leading to an increased bleeding risk, whereas others state that platelet aggregation is enhanced during mild hypothermia. Therefore, the aim of this study was to clarify whether standard or prolonged duration of targeted temperature management affected platelet aggregation. We randomised 82 comatose patients resuscitated after out-of-hospital cardiac arrest to either 24 hours (standard group) or 48 hours (prolonged group) of targeted temperature management at 33±1°C. Blood samples were collected 22 hours, 46 hours and 70 hours after reaching target temperature. Platelet aggregation was assessed by impedance aggregometry employing a Multiplate®Analyser, using the COLtest®, TRAPtest®, ADPtest® and ASPItest® as agonists, and with the results reported as area under the curve (AUC, AU*min). The platelet aggregation was below the normal range in all blood samples. No differences were observed between the standard group and the prolonged group in either of the blood samples (all p ≥ 0.11), except for a 24% decreased aggregation (95% confidence interval (CI) (10%;37%), p = 0.002) when using the COLtest® in the 46-hour sample. Comparing the 22-hour sample with the 46-hour sample in the prolonged group separately, we found no differences when employing the COLtest®, the ASPItest® or the ADPtest® in patients without the use of adenosine diphosphate receptor inhibitors (all p values ≥0.21), but aggregation induced by the TRAPtest® decreased by 14% (95% CI −8%;−20%), p < 0.001). We concluded that the platelet aggregation post cardiac arrest was below the normal range independent of the core temperature. Moreover, no substantial difference was found in platelet aggregation between standard and prolonged targeted temperature management.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

Avoidance vs use of neuromuscular blocking agent for improving conditions during tracheal intubation: a Cochrane systematic review

Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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Abstract Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random‐effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19–21.49, P<0.00001, TSA‐adjusted CI 1.85–95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49–7.15, P<0.00001, TSA‐adjusted CI 1.20–20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09–1.74, P=0.008, TSA‐adjusted CI 1.00–1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53–4.21, P=0.0003, TSA‐adjusted CI 0.27–21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.