Faculty Bibliography

BACKGROUND: Distraction technology suitable for the perioperative setting is readily available, but there is little evidence to show how it compares with oral midazolam in managing anxiety. Video glasses, which enable children to view and listen to cartoons and movies, may be used through the completion of inhaled induction. We compared the efficacy of oral midazolam and behavioral distraction with video glasses in managing preoperative anxiety in children. METHODS: In this prospective, randomized study, 96 children aged 4 to 9 years undergoing outpatient surgery were recruited to one of 3 intervention groups receiving midazolam, video glasses, or both. The Modified Yale Preoperative Anxiety Scale was the primary dependent measure used to assess anxiety at baseline before intervention, 20 minutes later at transport to the operating room (OR), and during mask induction. RESULTS: There was no significant increase in anxiety score within any group between baseline and OR transport (P = 0.21, 0.42, and 0.57 for midazolam, video glasses, and combined groups, respectively). An increase in anxiety, though not large enough to be clinically significant, was observed from baseline to induction in the midazolam and combined groups (P = 0.02 and 0.03) but not in the video glasses group (P = 0.38). Confidence intervals for pairwise comparisons in Modified Yale Preoperative Anxiety Scale changes among groups were all within a clinically significant difference of 15 units. CONCLUSIONS: The use of video glasses and midazolam alone or in combination maintains baseline levels of anxiety at time of transport to the OR and prevents significantly increased anxiety during induction of anesthesia in children. Video glasses are not inferior to midazolam for preoperative anxiolysis and provide a safe, noninvasive, nonpharmacologic, and pleasant alternative.

Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review highlights factors that predispose to severe bleeding, its management, and the most recent treatment and guidelines. Advances in obstetric care have provided physicians with the diagnostic tools to detect, anticipate, and prevent severe life-threatening maternal haemorrhage in most patients who have had prenatal care. In an optimal setting, patients at high risk for haemorrhage are referred to tertiary care centres where multidisciplinary teams are prepared to care for and deal with known potential complications. However, even with the best prenatal care, unexpected haemorrhage occurs. The first step in management is stabilization of haemodynamic status, which involves securing large bore i.v. access, invasive monitoring, and aggressive fluid management and transfusion therapy. Care for the patient with maternal bleeding should follow an algorithm that goes through a rapid and successive sequence of medical and surgical approaches to stem bleeding and decrease morbidity and mortality. With the addition of potent uterotonic agents and the advent of minimally invasive interventional radiological techniques such as angiographic embolization and arterial ligation, definitive yet conservative management is now possible in an attempt to avoid hysterectomy in patients with severe peripartum bleeding. If these interventions are inadequate to control the bleeding, the decision to proceed to hysterectomy must be made expeditiously. Recombinant factor VIIa is a relatively new treatment that could prove useful for severe coagulopathy and intractable bleeding.