Anaesthesia and Intensive Care Medicine最新文献

Assessment of emergency surgical patients aims to stratify risks of intended operation based on patient's condition and planned surgery, direct preoperative optimization and construct an anaesthetic plan accordingly. Compared to elective patients, emergency patients are susceptible to greater challenges including high aspiration risks, dehydration, electrolyte disturbances and impaired consciousness. Although only limited time is allowed, early recognition of these conditions allow appropriate intervention to minimize perioperative complications. In trauma patients, relevant history of injury regarding the type, mechanism and sites of injury is especially essential. They may present with difficult airway, ongoing bleeding and haemodynamic instability. This further complicates perioperative management where anaesthetic assessment is crucial to guide anaesthetic plans.

Pulmonary aspiration is an important complication of airway management that can result in serious morbidity and mortality. Inhalation of foreign substances can cause airway obstruction, chemical injury or secondary infections. Proper assessment of aspiration risk identifies patients at risk, allowing proper precautions to be performed. Point-of-care ultrasound can help with risk stratification. Premedication and rapid sequence induction should be considered in high-risk patients. Caution should be extended to the postoperative period.

Inappropriate fluid therapy can lead to significant morbidity and mortality. The maintenance of normal cellular and organ function relies on body fluid homeostasis. The concept of total body water compartmentalization, and the essential principles behind fluid physiology such as osmolarity and osmolality, osmosis and tonicity will be discussed. Factors that can influence body fluid distribution across different compartments and capillary fluid dynamics, such as the Starling forces and the role of endothelial glycocalyx layer will be discussed. Sodium, which plays a major role in plasma osmolality and compartment volume, requires tight regulation through various neuroendocrine mechanisms including the renin–angiotensin–aldosterone system (RAAS) and vasopressin. In addition to the regulation of the extracellular environment, cells have a number of specialized transmembrane transporters such as the sodium–potassium pump and the aquaporin channels to modulate water movement in response to osmotic stress.

Emergence and extubation are critical transitional phases in the perioperative period. Evidence has shown that complications occur more at extubation than intubation and induction. A comprehensive understanding of the various factors influencing emergence and extubation, potential complications, essential steps and different techniques employed can maximize patient outcomes and satisfaction. Vigilant monitoring and assessment of the patient's readiness for extubation are required at emergence. Reasons for delay and delirium in emergence must be screened and investigated so that corresponding treatment can be pursued. Haemodynamic stability, continued oxygen delivery, adequate analgesia and anti-emesis are the general objectives. Extubation is an elective procedure with the potential for unanticipated challenges and mortalities. Should extubation be determined appropriate, individualized planning and methodical preparation must precede the performance of extubation to avoid complications and failures. Risk stratification, airway assessment and optimization of physiological parameters are some of the necessary processes. Different extubation techniques are selected and performed to address specific physiological consequences and airway concerns. Guidelines and systematic approaches regarding emergence and extubation should be followed.

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.