Anaesthesia and Intensive Care Medicine最新文献

Humidification is concerned with the addition of water vapour to a gas and can be measured as either absolute or relative. Adequate humidification is a vital consideration in anaesthesia given that the anatomical source of natural gas humidification (the nasopharynx) is generally bypassed, which can lead to complications including hypothermia, thickening of respiratory secretions, mucus plugging and airway keratinization. Humidification may be passive or active. Equipment involved in passive humidification includes heat and moisture exchanger (HME) filters, soda lime and cold water baths, with these devices able to achieve varying efficiencies without extrinsic energy input. Active humidification devices (including hot water baths) are capable of delivering a higher relative humidity but are associated with higher cost and potential hazards. While not strictly classed as true humidification devices, nebulizers are considered in this article as they add water droplets into a gas flow using a Venturi system, spinning discs or ultrasound vibration technology.

A diagnosis of congenital heart disease increases perioperative risk for children having surgical procedures. Some will require anaesthesia at a specialist cardiac centre, while for others it is safe and appropriate to have their procedure in a local district general hospital. Children with complex congenital heart disease and poor physiological status carry the highest risk of cardiac arrest and mortality. Clinical features of cardiomyopathy, cyanosis, pulmonary hypertension, arrhythmia and cardiac failure are most likely to require specialist input and tertiary referral, whereas those with a preoperative stay of less than 10 days undergoing elective, minor surgery, who are older than 2 years of age and physiologically well may be safely anaesthetized in a district general hospital. In order to maximize safety, the anaesthetist must carry out a thorough preoperative assessment, have an understanding of the patient’s individual physiology and be prepared for the potential effects of general anaesthesia. Systemic vascular resistance is reduced by most induction agents and volatile anaesthetics; pulmonary vascular resistance is affected by changes in ventilation and gas exchange. The anaesthetist should also be alert to particular potential complications, such as arrhythmias, hypoxia, bleeding and cardiac arrest.

Safeguarding is an action that promotes the welfare of children and adults and aims to protect them from harm and maltreatment. This article will focus on children and the role of the anaesthetist. As an anaesthetist, you may not see signs of abuse often, but you will see children in different settings and should be able to clearly communicate any worrying concerns. Reading this article will increase your knowledge of laws and statutory advice for safeguarding.

Growth and maturation characterize the transition of neonates to adults. The physiological changes that children undergo present numerous pharmacological conundrums for the anaesthetist. Extensive changes in drug absorption, protein binding, metabolism and excretion during development result in wide variability in drug disposition. Pharmacodynamic differences and genetic polymorphisms further exacerbate these pharmacokinetic disparities. These changes directly affect drug efficacy and toxicity, and an awareness of this is crucial for clinicians involved in paediatric anaesthesia. Population-based pharmacokinetic–pharmacodynamic modelling provides a novel prospect in paediatric pharmacology research. Modelling has the potential to improve safety in clinical trials and enhance our understanding of drug disposition in vulnerable populations like preterm neonates. Although progress is occurring in developmental pharmacology, gaps remain, and a lot yet remains to be elucidated.

Children with acute and chronic associated medical conditions often present for surgical and radiological procedures. An understanding of the implications of these conditions for anaesthesia is important for preventing perioperative adverse events. In this article, we outline the relevant clinical features of some of the commonly encountered associated medical conditions and provide guidance on the current evidence for the perioperative anaesthetic management of these children.

Advances in paediatric anaesthetic equipment and monitoring continue to be made. While the mainstay of airway intubating equipment currently is the direct laryngoscope, videolaryngoscopes and endoscopes are increasing in their use. These continue to evolve, generating better quality pictures, with more sophisticated yet easier to use equipment. Vascular access in paediatric anaesthesia can be challenging. Ultrasound has become an integral piece of equipment in the management of these children with difficult access. As the population increases in weight, so the management of the obese child is now a reality. This requires thought and careful planning of their perioperative care. Newer techniques such as high flow nasal oxygen are useful both to prevent hypoxia at induction, but also to facilitate surgery. Total intravenous anaesthesia will be discussed with reference to paediatric algorithms and equipment. Neurological monitoring in the form of near-infrared spectroscopy and depth of anaesthesia monitoring are discussed with evidence relevant to paediatric practice.

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.