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Ethical issues in resuscitation and intensive care 复苏和重症监护中的伦理问题
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1016/j.mpaic.2024.08.006
Jill Keohone, Paul McConnell
Advances in the care of critically unwell patients have begun to blur the boundaries between life and death; coupled with an ageing population, intensive care physicians routinely make difficult decisions in their clinical work. The model of supported decision-making with patients has become standard, however, patients in the intensive care unit (ICU) are often unable to express their wishes at the point of admission. Recent legal cases have resulted in increased scrutiny upon the decisions we make when caring for patients unable to consent to treatment, due to incapacity and critical illness, particularly when they involve the limitation or discontinuation of life supporting therapies. A robust understanding and application of the moral, ethical and legal frameworks are useful to aid in making decisions in patients’ best interests when faced with clinical dilemmas on the ICU.
危重病人护理方面的进步已经开始模糊了生与死之间的界限;再加上人口老龄化,重症监护医生在临床工作中经常要做出艰难的决定。与病人一起辅助决策的模式已成为标准,但重症监护病房(ICU)的病人往往无法在入院时表达自己的意愿。最近的一些法律案件使我们在护理因丧失行为能力和危重病人而无法同意治疗的病人时所做出的决定,尤其是涉及限制或停止维持生命的疗法时,受到了更多的审查。对道德、伦理和法律框架的深刻理解和应用,有助于我们在重症监护病房面临临床困境时做出符合病人最佳利益的决定。
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引用次数: 0
Premedication 用药前
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1016/j.mpaic.2024.08.005
Ruth McGovern, Leo G Kevin
Administration of medications in advance of induction of anaesthesia, ‘premedication’, has a long history. With the earliest inhalational agents, ether and chloroform, induction was characterized by a prolonged period of involuntary movements, excessive salivation and feelings of severe anxiety. It became common practice, therefore, to premedicate patients with agents such as scopalamine (an early anticholinergic) to reduce secretions, and morphine, to reduce irritability and anaesthetic requirements. In the 1950s came intravenous induction agents and halogenated inhalation agents, and a smoother and more predictable induction and early maintenance phase, with much reduced salivation. The practice of premedication lingered however, although its main purpose was now simply to alleviate patient anxiety. The invention of benzodiazepines in the late 1950s was nicely timed to find for them a niche as favoured anxiolytic premedication. This persisted for many years. In modern anaesthesia practice, sedative/anxiolytic premedication is much less commonly used than heretofore. The pre-assessment consultation with the anaesthetist has largely replaced routine premedication for the purpose of alleviating anxiety, as several studies show that this can be quite effective in achieving a calm patient. The term premedication has lately taken on a broader meaning. It is now understood to include considerations regarding which of the patient's long-term medications should be withheld or continued in advance of their operation, and the introduction of medications with the aim of optimizing medical conditions or to improve certain peri-operative outcomes.
In this article we will first discuss premedication for the purposes of sedation/anxiolysis. We will then systematically examine some of the medications that are commonly the focus of preoperative decisions in the surgical patient. The list of medications discussed is by no means exhaustive. Finally, we will look at premedication in special patient populations.
在麻醉诱导前用药,即 "预处理",由来已久。最早使用乙醚和氯仿等吸入麻醉剂时,诱导过程中患者会出现长时间的不自主运动、过度流涎和严重焦虑等症状。因此,在诱导前给病人服用一些药物,如莨菪碱(一种早期的抗胆碱能药物)以减少分泌物,以及吗啡以减少刺激性和麻醉需求,成为一种常见的做法。20 世纪 50 年代,出现了静脉诱导剂和卤素吸入剂,诱导和早期维持阶段变得更加顺畅和可预测,唾液分泌也大大减少。然而,尽管预处理的主要目的现在只是为了减轻病人的焦虑,但这种做法仍然存在。20 世纪 50 年代末苯二氮卓类药物的发明恰逢其时,为它们找到了一个有利位置,成为最受欢迎的抗焦虑预处理药物。这种情况持续了许多年。在现代麻醉实践中,镇静剂/抗焦虑药的使用比以前要少得多。与麻醉师的预评估会诊已在很大程度上取代了以缓解焦虑为目的的常规预用药,因为多项研究表明,这对于使患者保持镇静相当有效。近来,预处理一词有了更广泛的含义。在本文中,我们将首先讨论以镇静/抗焦虑为目的的术前用药。本文将首先讨论以镇静/抗焦虑为目的的术前用药,然后我们将系统地研究手术患者术前决定通常会关注的一些药物。所讨论的药物清单并非详尽无遗。最后,我们将探讨特殊患者群体的术前用药。
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引用次数: 0
Drugs affecting coagulation 影响凝血的药物
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.06.008
James Barrowman, Ming Wilson
The clotting cascade is a complex process and is an important survival mechanism. Major haemorrhage and thromboembolic events remain major causes of increased morbidity and mortality. Drugs affecting coagulation have primarily been utilized to treat or reduce the risk of thromboembolic events. However, the recent progress in the management of major trauma and treating coagulopathy has resulted in further research and development of drugs that improve clotting function. Knowledge of drugs used for both clinical circumstances is now required when working in anaesthesia or intensive care.
凝血级联是一个复杂的过程,也是一种重要的生存机制。大出血和血栓栓塞事件仍然是发病率和死亡率上升的主要原因。影响凝血功能的药物主要用于治疗或降低血栓栓塞事件的风险。然而,最近在处理重大创伤和治疗凝血病方面取得的进展促使人们进一步研究和开发可改善凝血功能的药物。现在,在麻醉或重症监护领域工作时,需要了解用于这两种临床情况的药物。
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引用次数: 0
Acute and chronic airway obstruction in children 儿童急性和慢性气道阻塞
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.07.008
Graham Bell, William Shankey-Smith
Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients.
气道管理是麻醉师的基本技能之一。在儿童气道的发育过程中,从出生到成年期间会发生巨大的解剖学变化。对这些变化的了解将影响儿童期的气道规划。气道阻塞会使气道管理复杂化,任何从事儿童麻醉工作的麻醉师都应能够评估气道是否存在阻塞,并对阻塞原因进行鉴别诊断。本文旨在总结儿童气道的主要解剖特征、儿童气道阻塞的常见原因,并就如何管理这些患者提出建议。
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引用次数: 0
Developmental anatomy of the airway 气道的发育解剖
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.07.005
Thokozani M Zhande, Alasdair Howie
A thorough understanding of the airway anatomy, as well as the differences that exist between the paediatric and the adult airway is crucial for one to safely manage it. The human airway originates from the primitive foregut at 4 weeks' gestation and fully matures at 36 weeks’ gestation. At birth, the term neonate has a relatively large head, flat occiput, short neck, small mouth opening and a small mandible; features which make them prone to upper airway obstruction as well as a difficult laryngoscopy. Neonates are obligate nasal breathers; allowing them to breathe and suckle simultaneously. The Hagen–Poiseuille equation explains how nasal congestion causes obstruction in neonates which can lead to the development of significant respiratory distress.
The subglottic area of the airway is the most susceptible area to damage from intubation or instrumentation of the airway resulting in subglottic stenosis. Correct endotracheal tube sizing and meticulous attention to detail with respect to cuff pressure are essential to prevent damage to the airway.
全面了解气道解剖结构以及儿科气道与成人气道之间存在的差异,对于安全管理气道至关重要。人类气道在妊娠 4 周时起源于原始前肠,在妊娠 36 周时完全成熟。刚出生的新生儿头部相对较大,枕部扁平,颈部较短,口腔开口较小,下颌骨较小,这些特征使他们容易发生上呼吸道阻塞,喉镜检查也很困难。新生儿必须用鼻呼吸,因此可以同时进行呼吸和吸吮。Hagen-Poiseuille 等式解释了鼻塞如何导致新生儿呼吸道阻塞,进而引发严重的呼吸窘迫。气道的声门下区域是最容易因插管或气道器械操作而受损的区域,从而导致声门下狭窄。正确的气管导管尺寸和对充气罩囊压力的细致关注对于防止气道损伤至关重要。
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引用次数: 0
Nosocomial infections in the intensive care unit 重症监护室中的医院内感染
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.07.003
Frances Lanaghan, Peter Stenhouse
Nosocomial infections are associated with a significant morbidity, mortality, resource and financial burden in ICU. Critical care patients are at an increased risk of developing infections compared to patients elsewhere in hospital due to underlying comorbidities of the patient, the acute disease process and treatments required. There is a strong association with indwelling devices in the ICU population. As such, daily review of ongoing requirement for the invasive device and the application of care bundles, as well as the introduction of local policies targeting hand hygiene and infection control protocols to manage infections have been promoted. Ventilator-acquired pneumonia and catheter-related infections are most common. Management of these frequently involves empirical antimicrobials, although targeted therapy based on culture sensitivities and input from the local microbiology team and infection control team are suggested. There is an increasing burden of antimicrobial resistance in part due to the clinical condition of ICU patients and the frequent use of empirical broad-spectrum antibiotics.
非医院感染对重症监护病房的发病率、死亡率、资源和经济造成了巨大负担。与医院其他科室的病人相比,重症监护病人因其潜在的并发症、急性疾病过程和所需治疗而发生感染的风险更高。重症监护病房的病人与留置装置有很大关系。因此,我们提倡每天对侵入性装置的持续需求进行检查,应用护理捆绑包,并引入针对手部卫生和感染控制协议的地方政策,以控制感染。呼吸机获得性肺炎和导管相关感染最为常见。对这些感染的处理通常采用经验性抗菌药物,但建议根据培养敏感性以及当地微生物学团队和感染控制团队的意见进行有针对性的治疗。抗菌素耐药性的负担越来越重,部分原因是重症监护病房患者的临床状况和经验性广谱抗菌素的频繁使用。
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引用次数: 0
Assessment and management of the predicted difficult airway in neonates, infants and children 新生儿、婴儿和儿童预计困难气道的评估和管理
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.07.006
Johnny Kenth, Robert Walker
Few scenarios in medicine incite as much apprehension as encountering a child with an anticipated or unanticipated difficult airway. Navigating the paediatric airway landscape necessitates not only precision but also a highly adaptable approach due to the unique anatomical and physiological challenges presented by neonates, infants, and children. This review highlights the critical importance of comprehensive preoperative evaluation, integrating detailed patient history, meticulous physical examinations, and previous medical records to predict potential airway difficulties accurately. Central to the management strategy is the development of a robust, adaptable plan that incorporates the use of both basic airway devices and advanced technological aids such as video-laryngoscopes and flexible bronchoscopes. These tools aim to enhance success rates while minimizing patient trauma. Axiomatic to this discussion is the formulation of strategies that effectively mitigate hypoxia and ensure successful airway control with minimal attempts. The review also addresses special considerations, such as the strategic management of difficult extubation and the application of algorithmic approaches to airway management, equipping practitioners to handle both anticipated and unanticipated challenges proficiently. By amalgamating and contextualizing insights from clinical practice and evidence-based recommendations, this review aims to arm healthcare providers with the knowledge and skills essential for optimizing paediatric airway management outcomes, thereby enhancing safety and efficacy in paediatric anaesthesia and critical care.
在医学领域,很少有什么情况能像遇到预期或意料之外的气道困难患儿那样令人忧心忡忡。由于新生儿、婴儿和儿童在解剖学和生理学方面面临着独特的挑战,因此在儿科气道方面的导航不仅需要精确,还需要高度适应性的方法。这篇综述强调了全面术前评估的重要性,即结合详细的患者病史、细致的体格检查和以往的医疗记录,准确预测潜在的气道困难。管理策略的核心是制定稳健、适应性强的计划,其中既要使用基本气道设备,也要使用视频喉镜和软支气管镜等先进的辅助技术。这些工具旨在提高成功率,同时最大限度地减少对患者的创伤。对这一讨论而言,最重要的是制定策略,有效缓解缺氧并确保以最少的尝试成功控制气道。本综述还讨论了一些特殊考虑因素,如困难拔管的策略管理和气道管理算法方法的应用,使从业人员能够熟练应对预料之中和预料之外的挑战。本综述将临床实践中的见解与循证建议相结合,旨在为医护人员提供优化儿科气道管理结果所必需的知识和技能,从而提高儿科麻醉和重症监护的安全性和有效性。
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引用次数: 0
Sepsis in 2024: a review 2024 年的败血症:回顾
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.06.010
Jeffrey Wayland, J. Pedro Teixeira, Nathan D. Nielsen
Sepsis is responsible for tremendous morbidity, mortality, and healthcare expenditure worldwide. Over the past decade, the conceptualization of sepsis has shifted from one based upon an inflammatory response to one defined by a dysregulated immune response to infection and resulting organ dysfunction. The definitions of sepsis and septic shock were revised to improve their diagnostic specificity and facilitate accurate and timely diagnoses at the bedside. The core of sepsis management remains early identification and diagnostic testing, early antimicrobial therapy, and early haemodynamic resuscitation. Recently, there has been additional movement towards classifying and treating sepsis based on genotype, phenotype, and endotype, though these methods are not yet widely accessible or adopted. Current guidelines recommend that the first steps in treatment and resuscitation take place within 1 hour from when septic shock is suspected. Additional essential elements in the current sepsis management guidelines include using dynamic parameters to assess fluid responsiveness, a conservative fluid strategy following initial resuscitation (with subsequent de-resuscitation when possible), serial reassessments of haemodynamic status, and adaptable treatment plans. This review provides a summary of the most recent clinical trials and practice guidelines for the diagnosis and treatment of sepsis in the critical care setting.
败血症在全球范围内造成了巨大的发病率、死亡率和医疗开支。在过去十年中,败血症的概念已从基于炎症反应转变为对感染的免疫反应失调以及由此导致的器官功能障碍。对败血症和脓毒性休克的定义进行了修订,以提高其诊断特异性,便于在床边进行准确及时的诊断。脓毒症治疗的核心仍然是早期识别和诊断检测、早期抗菌治疗和早期血流动力学复苏。最近,根据基因型、表型和终末型对脓毒症进行分类和治疗的呼声越来越高,尽管这些方法尚未被广泛使用或采纳。目前的指南建议,在怀疑出现脓毒性休克后 1 小时内采取治疗和复苏的第一步。现行脓毒症治疗指南中的其他基本要素包括使用动态参数评估输液反应性、初始复苏后的保守输液策略(在可能的情况下随后进行去复苏)、连续重新评估血流动力学状态以及可调整的治疗计划。本综述总结了在重症监护环境中诊断和治疗败血症的最新临床试验和实践指南。
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引用次数: 0
Physical rehabilitation and critical illness 身体康复和危重病
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.06.012
Katherine Cox, Alana Rix, Carol L. Hodgson
With the evolution of interventions in the intensive care unit (ICU), an increasing number of patients are surviving critical illness. Survivors of critical illness commonly experience post-intensive care syndrome (PICS), which encompasses a range of physical, cognitive, social, and psychological impairments that persist well beyond discharge from hospital. Physical rehabilitation is an intervention that is implemented to prevent and treat the physical impairments that manifest as part of PICS. There is significant evidence to support functional, goal-directed physical rehabilitation interventions in ICU as it is shown to improve physical function without increasing the risk of adverse events. There are clear guidelines that outline the specific safety criteria for commencing physical rehabilitation in ICU, however, there is further research warranted to determine the optimal dosage. Beyond the ICU admission, there are limited recommendations regarding ongoing physical rehabilitation however there is emerging evidence to support the implementation of home-based telehealth programmes to help improve patient's strength, endurance, and quality of life. Regardless, it is recommended that physical rehabilitation is delivered as part of routine care during an ICU admission and continue throughout the transitions of care to enable the best possible recovery.
随着重症监护室(ICU)干预措施的发展,越来越多的病人在危重病中存活下来。危重病幸存者通常会出现重症监护后综合征(PICS),包括一系列身体、认知、社交和心理障碍,出院后仍会持续存在。身体康复是一种干预措施,旨在预防和治疗重症监护后综合征所表现出的身体损伤。有大量证据表明,在重症监护病房进行以目标为导向的功能性身体康复干预可以改善患者的身体功能,同时不会增加不良事件的风险。有明确的指南概述了在重症监护病房开始物理康复治疗的具体安全标准,但仍需进一步研究以确定最佳剂量。在重症监护室入院后,关于持续进行身体康复的建议很有限,但有新的证据支持实施基于家庭的远程保健计划,以帮助改善患者的体力、耐力和生活质量。无论如何,我们都建议在患者入住重症监护病房期间将身体康复作为常规护理的一部分,并在整个护理过程中持续进行,以实现最佳的康复效果。
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引用次数: 0
Self-assessment 自我评估
IF 0.2 Q4 ANESTHESIOLOGY Pub Date : 2024-10-01 DOI: 10.1016/j.mpaic.2024.08.014
Vijayanand Nadella
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引用次数: 0
期刊
Anaesthesia and Intensive Care Medicine
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