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Saturday, December 19, 2015

S͙U͙P͙E͙R͙I͙O͙R͙I͙T͙Y͙ A͙N͙D͙ E͙Q͙U͙I͙V͙A͙L͙E͙N͙C͙E͙ T͙R͙I͙A͙L͙S͙ ⬆️↔️


⬆️S͙U͙P͙E͙R͙I͙O͙R͙I͙T͙Y͙ T͙R͙I͙A͙L͙S͙

✔️Seek to establish that one treatment is better than another 

✔️The sample size is set so that there is high statistical power to detect a clinically meaningful difference between the two treatments 

↔️E͙Q͙U͙I͙V͙A͙L͙E͙N͙C͙E͙ T͙R͙I͙A͙L͙S͙

✔️Seek to test if a new treatment is similar  in effectiveness to an existing one

✔️Appropriate if the new treatment has certain benefits such as fewer side effects, being easier to use, or being cheaper 

✔️Designed to be able to demonstrate that, within given acceptable limits, the two treatments are equally effective 

✔️Equivalence is a pre-set maximum difference between treatments such that, if the observed difference is less than this, the two treatments are regarded as equivalent . The tighter the limits of equivalence are set, the larger the sample size that will be required 

✔️A serious condition requires tighter limits for equivalence than a less serious condition. 

✔️The calculated sample size tends to be bigger for equivalence trials than superiority trials 

🔴T͙H͙I͙N͙G͙S͙ T͙O͙ R͙E͙M͙E͙M͙B͙E͙R͙

👉🏿In general the design and implementation of equivalence trials is less straight forward than superiority trials 

👉🏿If patients are lost to follow-up or fail to comply with the trial protocol, then any differences between the treatments is likely to be reduced and so equivalence may be incorrectly inferred.

👉🏿So equivalence trials need very strict management and good patient follow-up to minimize these problems 

👉🏿It is often helpful to include a secondary analysis where subjects are analysed according to the treatment they actually received, ‘per protocol’ analysis 

#MedicalResearch ,#ClinicalResearch , #MedicalStatistics , #BioStatistics , #AnaesthesiaResearch , #Statistics ,#research

Reference: Oxford Handbook of Medical Statistics, Janet L. Peacock , Philip J. Peacock

Thursday, December 17, 2015

XENON-THE STRANGER🌪


🍭colorless, odourless, tasteless gas

🍭four times denser than air. 

🍭density and viscosity are substantially higher than those of other inhalational anaesthetics. 

🍭occurs in extremely low concentrations (0.0875 ppm) in the atmosphere, hence its name from the Greek ‘xenos’ meaning ‘stranger’. 

🍭Xenon has been used experimentally as an anaesthetic for more than 50 years 

🍭Recently there has been a renewed interest in xenon as a safe, effective and more environmentally friendly substitute for nitrous oxide (Sanders et al. 2003). 

🍭manufactured by fractional distillation of liquefied air, currently at a cost of US $10 per litre (i.e. about 2,000 times the cost of producing N2O). This high cost is the major factor limiting its more widespread use, even when used in low-flow delivery systems. 

🍭Xenon has many of the properties of an ideal anaesthetic. 

🍭Its blood/gas partition coefficient (0.12) is lower than that of any other anaesthetic, giving rapid induction and emergence. 

🍭It is unlikely to be involved in any biochemical events in the body, and is not metabolised. 

🍭Xenon causes no significant changes in myocardial contractility, blood pressure or systemic vascular resistance, even in the presence of severe cardiac disease (Sanders et al. 2005). 

🍭The unique combination of analgesia, hypnosis, and lack of haemodynamic depression in one agent would make xenon a very attractive choice for patients with limited cardiovascular reserve 

🍭In contrast to other inhaled anaesthetic agents, xenon slows the respiratory rate and increases the tidal volume, thereby maintaining minute ventilation constant. 

🍭Airway pressure is increased during xenon anaesthesia, due to its higher density and viscosity rather than direct changes in airway resistance (Baumert et al 2002). 

🍭Because of its high cost xenon must be used in low-flow closed circuits. Crucial to this method of administration is accurate measurement of the concentration of xenon in the circuit. This measurement is generally difficult as xenon is  diamagnetic and does not absorb infrared radiation (commonly used to measure the  concentrations of other agents), and its low reactivity precludes the use of specific fuel cell or electrode-type devices. 

🍭Xenon conducts heat better than other gases, and a technique based on thermal conductivity has proved to be effective (Luginbuhl et al 2002). 

🍭Because xenon is heavier than air, the speed of sound is slower in xenon than that in air, and this difference has been also been used to measure xenon concentration. 

🍭Because xenon is a normal constituent of the atmosphere, it does not add to atmospheric pollution when emitted from the anaesthesia circuit. This is in contrast to the other inhalational anaesthetics, which have ozone-depleting potential and pollute the atmosphere when released from the anaesthesia system (Marx et al. 2001). 

🍭On a molecular basis, N2O is 230 times more potent as a greenhouse gas than carbon dioxide. N2O released as a waste anaesthetic contributes roughly 0.1% of total global warming. The lifetime of N2O in the atmosphere is long—approximately 120 years. 

🍭The anaesthetic actions of xenon are thought to result primarily from noncompetitive inhibition of  NMDA receptors (De Sousa et al. 2000), a property it shares with nitrous oxide. 

🍭In common with other NMDA receptor antagonists, xenon appears to have neuroprotective properties (Sanders et al. 2003). 

🍭Xenon is also an excellent analgesic, an action mediated by NMDA receptors (De Sousa et al. 2000). 

🍭Xenon also inhibits the plasma membrane Ca 2+   pump, altering neuronal excitability and inhibiting the nociceptive responsiveness of spinal dorsal horn neurones. 


(Reference : Jürgen Schüttler •  Helmut Schwilden Modern Anesthetics ,Handbook of Experimental Pharmacology, vol 182)

EXAMPLES OF RESEARCH QUESTIONS🔢



(From : Oxford Handbook of Medical Statistics, Janet L. Peacock, Philip J. Peacock, P:5)

❓What is the prevalence of diabetes mellitus in the population? 
🔴This is a simple descriptive study 

❓How effective is influenza vaccination in the community-based elderly? 
🔴This is a comparative study, comparing individuals who had vaccines with those who did not 

❓Does lowering blood pressure reduce the risk of coronary heart disease? 
🔴This is an evaluative study, investigating the effi cacy of lowering blood pressure 

❓Is prognosis following stroke dependent on age at the time of the event? 
🔴This is an observational study 

❓Why does smoking increase the risk of heart disease? 
🔴This is an explanatory study investigating the mechanism behind an observed relationship 

❓What evidence is there for the effectiveness of antidepressants in treating depression? 
🔴This study is a meta-analysis of existing interventional studies


STATES ASSOCIATED WITH AUTONOMIC DYSFUNCTION⚠️


💠Diabetes

💠Hypertension

💠Renal failure

💠Aging

💠Postcarotid endarterectomy 

💠Spinal cord injury

💠Shy-Drager Syndrome

💠Idiopathic orthostatic hypotension 

💠Chronic alcoholism

💠Posterior flossa tumors/surgery 

💠Guillain-Barré syndrome 

💠Malignancy

RISK FACTORS FOR POST OPERATIVE COGNITIVE DYSFUNCTION


Wednesday, December 16, 2015

📽---->>PROJECT THE RAYS CORRECTLY



(Basic facts about projection in X ray films)

📐Postero-anterior (PA) will not produce as much magnification of the heart and mediastinum as an antero-posterior (AP) projection. So PA films are the preferred ones.

📐A PA film is taken with the film cassette in front of the patient and the beam delivered from behind with the patient in an upright position. 

📐Portable films and those taken in ICUs are all AP projection. 

📐The supine position causes distension of the upper lobe blood vessels, which may be confused with elevated left atrial pressure 

📐A lateral X-ray is useful in localising lesions in the AP dimension, locate lesions behind the left side of the heart or in the posterior recesses of the lungs. 

📐A left lateral (with the left side of the chest against the film and the beam projected from the right) is the standard projection. 

📐The heart is magnified less with a left lateral as it is closer to the film. 

📐To visualize lesions in the left hemithorax, obtain a left lateral film and for right-sided lesions a right lateral. 

📐Expiratory films are used to assess air trapping in bronchial obstruction such as a foreign body. 

📐A pneumothorax always appears larger on an expiratory film and occasionally a small pneumothorax may only be visible on expiration. 

📐Films if accidentally taken in expiration, can result in spurious magnifcation of the heart and mediastinum.

#xray ,#radiology ,#imaging , #XrayBasics , #anaesthesia 

Reference: Radiology for Anaesthesia and Intensive Care (Richard Hopkins, Carol Peden and Sanjay Gandhi)

〽️DIAPHRAGMATIC EVENTRATION



🔹 typically affects only a segment of the hemidiaphragm

🔹 is due to incomplete muscularisation of the diaphragm with a thin membranous sheet replacing the normal diaphragmatic muscle. 

🔹 Over time this region stretches and on inspiration does not contract normally. 

🗣Sudden rupture can occur with increase in intra-abdominal pressure (e.g. coughing, straining during light anesthesia or extubation etc)

🔹True rupture (if it happens)  - Effects: 

🔹mass effect of the abdominal viscera-->direct compression of the heart, mediastinal shift 

🔹Compression of vena cava and pulmonary veins--> impairs venous return, decreased cardiac output. 

👉🏿So we should maintain adequate depth of anaesthesia 

👉🏿Avoid Nitrous oxide (expansion of intra-abdominal viscera can impair the circulation and respiration)

#DiaphragmaticEventration , #eventration , #anaesthesia , #anesthesia , #DiaphragmaticHump ,#Radiology ,#cxr ,#ChestXray

Reference: Anaesthetic Management of an Adult Patient with Diaphragmatic Eventration
Azhar Rehman*, Zafar Ali Mirza, Saad Yousuf and Asma Abdus Salam, radiopaedia.org

🔴T̠H̠E̠ B̠A̠S̠I̠C̠S̠ O̠F̠ R̠E̠S̠P̠I̠R̠A̠T̠O̠R̠Y̠ P̠H̠Y̠S̠I̠O̠L̠O̠G̠Y̠ & A̠B̠G̠🔴 A FEW POINTS



⚡️CO2  is the most important stimulus for respiration

😇Receptors for CO2  are found in the medulla of the brain (central chemoreceptors)

❤️Receptors for O2  are found mainly in carotid and aortic bodies 

👑CO2  is the more important gas as the body has more capacity to store CO2  than O2 or hydrogen ions 

1️⃣0️⃣In normal people at sea level, only 10% of the respiratory drive is due to hypoxic stimulation. 

▶️◀️Unlike the central stimulation of hypercapnia, hypoxia causes central depression of the respiratory drive. 

▶️◀️Acidosis (high H + /low blood pH) stimulates respiration; conversely alkalosis depresses it.

😳For gas exchange, the lungs provide an interface of total surface area about 55 m2 via 700 million alveoli

🎯Alveolar ventilation’ is that part of the total ventilation (i.e. all gas entering the lungs) that participates in gas exchange with pulmonary capillary blood; it is equal to total ventilation minus the ventilation of the conducting airways (i.e. dead-space ventilation).The average alveolar ventilation is about 4 L/min.

📥The alveolar–arterial oxygen gradient ( P(A-a)O2 ) is a measure of the oxygen that has reached the arterial blood supply as a ratio of the total oxygen in the alveoli. It is a useful index of pulmonary gas exchange function. 

➡️This requires that three elements are working correctly: 

⏺Circulatory anatomy is normal. Anomalies such as ASD & PDA can cause anatomical shunting,  i.e. venous blood passes through routes that are not exposed to alveolar air 

⏺Ventilation and perfusion are matched 

⏺The respiratory membrane allows sufficient free diffusion of gases between air and blood.  A diffusion defect impairs the alveolar–capillary membrane, e.g. in interstitial lung fibrosis

🔢In a healthy individual breathing room air (at FiO2 21) the PO2  in alveolar air is 104 mmHg and in arterial blood 95 mmHg . PAO2 exceeds PaO2 by 15 mmHg .Thus, at an FiO2 of 21, the P(A–a)O2 is 15 mmHg 

🎭In blood, CO2  is present as: 

✔️Dissolved in blood plasma (5.3% in arterial blood)

✔️Bound to haemoglobin as carbaminohaemoglobin within erythrocytes (4.5%) 

✔️In the form of bicarbonate attached to a base (90%) As CO2 diffuses from peri


Reference:"Understanding ABGs & Lung Function Tests"  Muhunthan Thillai, Keith Hattotuwa

Sunday, December 13, 2015

RESPIRATORY STIMULANTS AND DEPRESSANTS

🏀Drugs that act as Respiratory stimulants 

⤴️Acetazolamide 
⤴️Aminophyllines 
⤴️Doxapram  
⤴️Progesterone 
⤴️Salicylates

🏀Drugs that act as Respiratory depressants 

⤵️Alcohol 
⤵️Anaesthetics 
⤵️Anticholinergics 
⤵️Antihistamines 
⤵️Barbiturates 
⤵️Benzodiazepines 
⤵️Opioids

#pharmacology , #pulmonology , #icu , #sedation , #anesthesia , #anaesthesia , #criticalcare

🤓MNEMO>



N͞͞A͞͞T͞͞U͞͞R͞͞A͞͞L͞͞L͞͞Y͞͞ O͞͞C͞͞C͞͞U͞͞R͞͞R͞͞I͞͞N͞͞G͞͞ O͞͞P͞͞I͞͞O͞͞I͞͞D͞͞S͞͞

😉P͎A͎P͎A͎ C͎a͎r͎e͎s͎ M͎O͎R͎e͎ T͎H͎a͎n͎ N͎A͎T͎U͎R͎E͎😉

PAPAVERINE CODEINE MORPHINE THEBAINE

#mnemonics ,#MedicalMnemonics , #anaesthesia