ImportanceWhether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain.ObjectiveTo determine whether SDD reduces in-hospital mortality in critically ill adults.Design, Setting, and ParticipantsA cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021.InterventionsICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs.ResultsOf 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, −1.7% [95% CI, −4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, −11.0%; 95% CI, −14.7% to −7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, −1.95%; 95% CI, −3.5% to −0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, −0.24%; 95% CI, −0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (−3.3% vs −1.59%; mean difference, −1.71% [1-sided 97.5% CI, −∞ to 4.31%] and 0.88% vs 0.55%; mean difference, −0.32% [1-sided 97.5% CI, −∞ to 5.47%]) in the first and second periods, respectively.Conclusions and RelevanceAmong critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit.Trial RegistrationClinicalTrials.gov Identifier: NCT02389036

Forum 785postepidural injection (median 122 minutes) and lasted from 30 to 60 minutes (median 45 minutes). This was not statistically significant. Vomiting occurred twice in the fentanyl group at 10 and 70 minutes after injection and once in the saline group (12 minutes after injection). Nausea occurred twice in the fentanyl group ( I 1 and 30 minutes after injection) compared to three times in the saline group (45, 50 and 140 minutes after injection).Nitrous oxide was given before the epidural in five mothers in the fentanyl group and to seven mothers in the saline group. Nitrous oxide had no influcncc on shaking. Pethidine 100 mg was administered to only one mother 4 hours before epidural insertion (saline group). DiscirrsioiiThe cause of shaking related to epidural analgesia is still unknown. Loss of body heat secondary to sympathetic blockade is an unlikely explanation since the onset of shaking is so rapid after epidural injection and is unusual after subarachnoid block. The evidence for causal relationship between injectate temperature and shaking is equivocal. Two studies showed no difference in the incidence of shaking when bupivacaine was warmed to body temperature, though thcre was a slight reduction in incidence when both the bupivacaine and the intravenous fluids were warmed. , 4 Having tried warming bupivacaine in this unit (in an uncontrolled manner) we do not believe injectate temperature is relevant. Bromage5 suggested that a differential block is responsible; it interrupts the warm sensation, and transmits a cold one which results in shaking. However, in this study there was no correlation between top-up dose and duration of shaking or its onset and this has bccn reported p r e v i~u s l y .~ Animal experimentation has found opioid receptors to be important in this field. Cold, shaking, anaesthetised rats stop shaking when given intraventricular beta-endorphin but this recurs when they are given naloxone.6 Brownridge3 demonstrated that cpidural pethidine is effective in abolishing shakes, and parenterally administered pethidine reduces it after general anaesthesia.' Fentanyl given parenterally (in equipotent doses to those used above) does not reduce shaking after general anaesthesia,* yet as we have demonstrated is effective in its abolition when associated with epidural analgesia. This suggests a spinal cord action. Epidural fentanyl stopped the shaking when the shaking preceded epidural analgesia and also where it was associated with an epidural Caesarean section. Ackno wlcdgmentsWe thank Dr J.S. Crawford for his advice and encouragcment and also the midwives of the Birmingham Maternity Hospital for their help with this study. Incentivc spirometers are devices designed to encourage patients to take sustained maximal inspirations. They have been shown to reduce pulmonary atelectasis after cardiac surgery,' , z but evidence for their value after upper abdominal surgery is This study was designed to assess the benefits of incentive spirometry after cholecystcctomy in terms of clinical evidence ...

SummaryA case of massive swelling of the tongue and face following posterior cranial fossa surgery in the sitting position is described. Prolonged tracheal intubation was required postoperatively. This serious complication appeared to relate to prolongedflexion of the neck.

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SummaryA I5 mg dose of isobaric bupivacaine O.S% solution for spinal analgesia was compared with a clinically indicared dose of hyperbaric amerhocaine 1% solution (1&16 mg) in 123 patients undergoing orthopaedic, urological and general surgical procedures. The 63 patients who received bupivacaine had a more limited spread of analgesia, which lasted longer and was accompanied by less hypotension and fewer complications than those who received arnethocaine.