Anaesthesia and Intensive Care Medicine最新文献

Renal transplantation is the most common solid organ transplant performed and it is the treatment of choice for end-stage renal disease (ESRD). These patients present a unique set of challenges to the anaesthetist, who has a crucial role in the immediate success of the transplanted organ. This article describes the assessment of the adult patient for renal transplantation, the perioperative management and the aims in the postoperative period.

This review describes the assessment and listing of the patient for liver transplantation and some of the perioperative challenges specific to this group of patients. The principles of the postoperative management in the intensive care unit are discussed as well as some of the signs of early graft dysfunction. Increasingly complex patients with advanced liver disease are receiving grafts from more marginal donors and this can present significant challenges to the transplant team. The anaesthetist and intensivist play a vital role in determining outcome in the perioperative period and must work collaboratively with surgeons and hepatologists to achieve the best patient outcomes.

Intensive care medicine has higher per-patient costs, staffing ratios and intervention rates than many other healthcare settings. Besides the economic impact, treatment is burdensome; the decision to admit patients to the intensive care unit must be carefully balanced against the prospect of meaningful recovery. With advances in medicine and surgery, a higher proportion of increasingly comorbid patients with advanced age are presenting to intensive care. Even in developed countries, resources remain limited, and clinicians must carefully consider to whom these resources are allocated in order to maximize benefit. Resource scarcity during the recent coronavirus disease pandemic presented further challenges. Classical ethical principles can be interwoven with newer models of ethical decision-making to help the intensive care team maximize the utility of available resources.

The concept of brain and brainstem death developed from the observation of apnoeic comatose patients. In the UK, the diagnosis of brainstem death is made by clinically testing brainstem function once specific pre-conditions have been met. The exact definition of brain death and some details regarding the tests required to make this diagnosis vary across the globe. However, the majority of tests carried out are similar to those in the UK. In this review we define brainstem death and the clinical tests used to confirm it. The use of ancillary testing can have a role in patients where clinical tests are not possible and this is also discussed.

This article provides a brief historical overview, description of types of donation, determination of death by circulatory and neurological criteria, dead donor rule, conduct of donation and retrieval and the ethical challenges that arise in this sphere.

Solid organ transplantation has progressed dramatically over the last 50 years; however, rejection still remains one of the barriers to successful transplantation. Immunological processes underlying the mechanisms of rejection are well described and numerous pharmacological agents exist to help suppress a recipient's immune system in order to prolong graft survival. Furthermore, clinician decisions and actions during both the work-up of a potential transplant recipient and in the perioperative phase can impact upon the immunological status of an individual and the likelihood of successful solid organ transplantation. In this article we aim to describe the key processes involved in solid organ immunology and their relevance in anaesthetic practice.

Injury or foreign invasion will instigate a cascade of events directed at eliminating the intruder and augmenting the healing process. This involves the unification of two separate processes (inflammatory and immune processes) to provide an effective host defence. Chemical mediators converge on the site of tissue damage and exert local and distant effects. The immune response is divided into innate and acquired immunity. The immediate, non-specific innate response, combined with the specifically targeted acquired response, provide our major defence mechanisms. Lymphocytes and immunoglobulins are the hallmark of acquired immunity. Regulation of these interlinked systems provide cohesion and a group of soluble proteins called cytokines have a major role. Protective immune mechanisms can sometimes cause detrimental effects to the host. We discuss and classify allergic reactions, in particular, the most severe and potentially life-threatening form – anaphylaxis.

Organ donation provides a treatment for patients with severe organ dysfunction that is both life-saving, and life-enhancing. Most organs in the UK are transplanted after deceased donation; clinical staff working in the intensive care unit must be familiar with the principles of deceased organ donation and be able to support both the donor and their family through this process. The pathophysiological response to neurological injury after Death by Neurological Criteria requires optimization to preserve organ function and allow donation of healthy organs to proceed. Recent advances in in-vivo and ex-vivo perfusion techniques have revolutionized some aspects of organ retrieval practice. Donation after Circulatory Death now accounts for one-third of cardiac transplants, which were recently exclusively obtained from Donation after Brainstem Death. Accordingly, an up-to-date knowledge base of this rapidly evolving field is vital. This article will focus on deceased organ donation, specifically the processes of Donation after Brainstem Death and Donation after Circulatory Death, and the physiological support of the potential organ donor in the intensive care unit.