Anaesthesia and Intensive Care Medicine最新文献

Patient recovery is a period of active patient monitoring and management during which time airway reflexes return and respiratory and cardiovascular stability should be achieved. The post-anaesthesia care unit (PACU) is the specially designed clinical area in which staff trained in the recognition and management of potential complications arising during this time care for patients. National guidance on the responsibilities and training of staff, the monitoring required during the recovery period and criteria for discharge serves to ensure patient safety and efficient theatre throughput.

The maintenance of tissue fluid homeostasis is an essential task in perioperative care. Fluid balance, when managed accurately and safely, can influence perioperative outcomes and reduce significant patient morbidity and mortality. Surgical and critically ill patients are subjected to disrupted physiology due to a combination of hypovolaemia, systemic inflammation and local glycocalyx damage, with resulting impairment of normal fluid regulation. To optimize fluid management and achieve adequate end-organ perfusion, cardiac output monitoring methods are increasingly employed to guide perioperative fluid therapy. In recent years, the additional importance of optimizing microcirculation has been of great interest. Fasting and perioperative fluid strategies are similarly integral in fast-track surgery pathways, despite aspects pertaining to volumes and types of fluid still up for clinical debate. Fluid burden commonly exceeds volumes consciously given due to hidden volumes used in drug delivery, and the importance of comprehensive overview on fluid prescription should not be understated.

Perioperative venous thromboembolism (VTE) has a significant impact on morbidity and mortality. Prevention of perioperative VTE begins with risk assessment and formulating a thromboprophylaxis strategy that balances bleeding and thrombosis risks. A standardized approach to assess these risks using relevant guidelines can help direct appropriate use of mechanical and pharmacological prophylaxis. Nevertheless, acute pulmonary embolism (PE) can present in the perioperative period. This brief review summarizes current diagnostic algorithms including the use of transthoracic echocardiography to guide immediate management of acute PE, particularly in an intraoperative setting.

Perioperative medicine is a specialized, rapidly developing field that focuses on comprehensive patient care from the moment they consider surgery until their full recovery. This patient-centred, multidisciplinary, and integrated approach aims to provide optimal medical care to those undergoing surgical procedures. The goal is to enhance outcomes and patient satisfaction, while also reducing the economic burden on healthcare and society.

Perioperative medicine has become increasingly important especially with the rising number of surgical procedures, as well as an aging population. Older patients undergoing surgery often face challenges due to their advanced age and multiple comorbidities, complicating their recovery journey.

The success of perioperative medicine hinges on the preoperative assessment, where the aim is to identify at-risk patients and modifiable risk factors. Through this process, personalized care can lead to improved perioperative outcomes. The purpose of this article is to give a general account on how patients should be assessed systematically, and more importantly to show the rationale behind such assessments in an elective setting. It is impossible to cover assessment for all comorbidities and surgical pathologies in one article, so further specific review articles should address them individually.

Understanding human temperature physiology and its management has significant relevance across all clinical specialties. Not only does it influence anaesthetic drug metabolism, it also affects perioperative outcome. Thermal management is equally crucial in a multitude of clinical settings. In the neonatal intensive care unit (ICU), paediatricians must carefully manage preterm babies' temperature. In the accident and emergency department, physicians manage near-drowning patients. Post-operative care for a patient with a traumatic brain injury in an adult ICU requires strict temperature control to prevent secondary brain injury. This article hopes to bring forth some key principles of thermoregulation, however temperature measurements and warming strategies are to be covered in other review articles. The article also highlights some important concepts of thermal-dysregulation such as fever and heat stroke, especially in the context of an ageing population and global warming.

Postoperative nausea and vomiting (PONV) is a common distressing symptom for patients undergoing surgery and anaesthesia, with incidence ranging from 30% in the general population up to 80% in the high-risk cohort. PONV increases patient dissatisfaction, with additional surgical and anaesthetic implications such as aspiration, wound dehiscence and raised intracranial pressure

This article highlights multifactorial aetiologies of PONV including patient, anaesthetic and surgical related factors. Neuropharmacology including activation of various receptors (dopaminergic, muscarinic, serotonergic) and cranial nerves VIII (acoustic-vestibular), IX (glossopharyngeal) and X (vagus nerve) is discussed. The most up-to-date PONV management and novel therapies are also discussed after literature review.

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic anti-emetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl-choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of anti-emetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist, and nabilone, a synthetic cannabinoid.

The delivery of anaesthesia to children and young people provides unique challenges. A careful, systematic approach to assessment and preparation can deliver a positive experience for the child, carers and staff while mitigating potential complications. Preparation for anaesthesia should encompass information-gathering, assessment and planning for anatomical, physiological, social and behavioural elements specific to the child and the surgery. Delivery of appropriate information, consent and fasting are also key elements of ensuring positive perioperative outcomes. We consider the common components of preparation for the delivery of safe paediatric anaesthesia.

Airway management is undertaken to deliver oxygen, remove carbon dioxide and protect against pulmonary aspiration. This article describes the equipment utilized by airway providers in order to achieve these aims, aided by their relevant knowledge, skills and experience. The use of this equipment forms the basis of core airway management techniques, including facemask ventilation, use of supraglottic airway devices, laryngoscopy, awake tracheal intubation and front-of-neck access.

General anaesthesia is a state of controlled unconsciousness utilized to perform a therapeutic procedure. The aims of anaesthesia have traditionally been summarized by the triad of hypnosis, analgesia and muscle relaxation. The process begins with preoperative assessment of the patient before ensuring equipment and drugs are available and safe to use. Anaesthesia commences with administration of induction agents, delivered via inhalational or intravenous routes. Consideration of airway management is an essential component of the induction phase of anaesthesia. The choice and dose of induction agent is multifactorial and can include: co-morbidity; type of surgery, age and patient physiology. Following induction of anaesthesia, the maintenance phase of anaesthesia can be delivered via an inhalation or intravenous route. The administration of anaesthetic drugs is generally associated with rapid loss of airway reflexes and cardiorespiratory changes. Complications of general anaesthesia can include awareness, aspiration, anaphylaxis, airway loss, laryngospasm, cardiovascular instability, malignant hyperpyrexia and dental damage. Meticulous attention to detail is vital to minimize the risk of these potential complications.