世界危重病急救学杂志(英文版)最新文献

The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.

Extracorporeal membrane oxygenation (ECMO) has emerged as a vital circulatory life support measure for patients with critical cardiac or pulmonary conditions unresponsive to conventional therapies. ECMO allows blood to be extracted from a patient and introduced to a machine that oxygenates blood and removes carbon dioxide. This blood is then reintroduced into the patient's circulatory system. This process makes ECMO essential for treating various medical conditions, both as a standalone therapy and as adjuvant therapy. Veno-venous (VV) ECMO primarily supports respiratory function and indicates respiratory distress. Simultaneously, veno-arterial (VA) ECMO provides hemodynamic and respiratory support and is suitable for cardiac-related complications. This study reviews recent literature to elucidate the evolving role of ECMO in trauma care, considering its procedural intricacies, indications, contraindications, and associated complications. Notably, the use of ECMO in trauma patients, particularly for acute respiratory distress syndrome and cardiogenic shock, has demonstrated promising outcomes despite challenges such as anticoagulation management and complications such as acute kidney injury, bleeding, thrombosis, and hemolysis. Some studies have shown that VV ECMO was associated with significantly higher survival rates than conventional mechanical ventilation, whereas other studies have reported that VA ECMO was associated with lower survival rates than VV ECMO. ECMO plays a critical role in managing trauma patients, particularly those with acute respiratory failure. Further research is necessary to explore the full potential of ECMO in trauma care. Clinicians should have a clear understanding of the indications and contraindications for the use of ECMO to maximize its benefits in treating trauma patients.

Background: Cardiac arrest caused by acute pulmonary embolism (PE) is the most serious clinical circumstance, necessitating rapid identification, immediate cardiopulmonary resuscitation (CPR), and systemic thrombolytic therapy. Extracorporeal CPR (ECPR) is typically employed as a rescue therapy for selected patients when conventional CPR is failing in settings where it can be implemented.

Case summary: We present a case of a 69-year-old male who experienced a prolonged cardiac arrest in an ambulance with pulseless electrical activity. Upon arrival at the emergency department with ongoing manual chest compressions, bedside point-of-care ultrasound revealed an enlarged right ventricle without contractility. Acute PE was suspected as the cause of cardiac arrest, and intravenous thrombolytic therapy with 50 mg tissue plasminogen activator was administered during mechanical chest compressions. Despite 31 minutes of CPR, return of spontaneous circulation was not achieved until 8 minutes after initiation of Veno-arterial extracorporeal membrane oxygenation (ECMO) support. Under ECMO support, the hemodynamic status and myocardial contractility significantly improved. However, the patient ultimately did not survive due to intracerebral hemorrhagic complications, leading to death a few days later in the hospital.

Conclusion: This case illustrates the potential of combining systemic thrombolysis with ECPR for refractory cardiac arrest caused by acute PE, but it also highlights the increased risk of significant bleeding complications, including fatal intracranial hemorrhage.

Background: Coronavirus disease 2019 (COVID-19) is strongly associated with an increased risk of thrombotic events, including severe outcomes such as pulmonary embolism. Elevated D-dimer levels are a critical biomarker for assessing this risk. In Gabon, early implementation of anticoagulation therapy and D-dimer testing has been crucial in managing COVID-19. This study hypothesizes that elevated D-dimer levels are linked to increased COVID-19 severity.

Aim: To determine the impact of D-dimer levels on COVID-19 severity and their role in guiding clinical decisions.

Methods: This retrospective study analyzed COVID-19 patients admitted to two hospitals in Gabon between March 2020 and December 2023. The study included patients with confirmed COVID-19 diagnoses and available D-dimer measurements at admission. Data on demographics, clinical outcomes, D-dimer levels, and healthcare costs were collected. COVID-19 severity was classified as non-severe (outpatients) or severe (inpatients). A multivariable logistic regression model was used to assess the relationship between D-dimer levels and disease severity, with adjusted odds ratios (OR) and 95%CI.

Results: A total of 3004 patients were included, with a mean age of 50.17 years, and the majority were female (53.43%). Elevated D-dimer levels were found in 65.81% of patients, and 57.21% of these experienced severe COVID-19. Univariate analysis showed that patients with elevated D-dimer levels had 3.33 times higher odds of severe COVID-19 (OR = 3.33, 95%CI: 2.84-3.92, P < 0.001), and this association remained significant in the multivariable analysis, adjusted for age, sex, and year of collection. The financial analysis revealed a substantial burden, particularly for uninsured patients.

Conclusion: D-dimer predicts COVID-19 severity and guides treatment, but the high cost of anticoagulant therapy highlights the need for policies ensuring affordable access in resource-limited settings like Gabon.

Diabetic foot attack (DFA) is the most severe presentation of diabetic foot disease, with the patient commonly displaying severe sepsis, which can be limb or life threatening. DFA can be classified into two main categories: Typical and atypical. A typical DFA is secondary to a severe infection in the foot, often initiated by minor breaches in skin integrity that allow pathogens to enter and proliferate. This form often progresses rapidly due to the underlying diabetic pathophysiology of neuropathy, microvascular disease, and hyperglycemia, which facilitate infection spread and tissue necrosis. This form of DFA can present as one of a number of severe infective pathologies including pyomyositis, necrotizing fasciitis, and myonecrosis, all of which can lead to systemic sepsis and multi-organ failure. An atypical DFA, however, is not primarily infection-driven. It can occur secondary to either ischemia or Charcot arthropathy. Management of the typical DFA involves prompt diagnosis, aggressive infection control, and a multidisciplinary approach. Treatment can be guided by the current International Working Group on the Diabetic Foot/Infectious Diseases Society of America guidelines on diabetic foot infections, and the combined British Orthopaedic Foot and Ankle Society-Vascular Society guidelines. This article highlights the importance of early recognition, comprehensive management strategies, and the need for further research to establish standardized protocols and improve clinical outcomes for patients with DFA.

Infection is a public health problem and represents a spectrum of disease that can result in sepsis and septic shock. Sepsis is characterized by a dysregulated immune response to infection. Septic shock is the most severe form of sepsis which leads to distributive shock and high mortality rates. There have been significant advances in sepsis management mainly focusing on early identification and therapy. However, complicating matters is the lack of reliable diagnostic tools and the poor specificity and sensitivity of existing scoring tools i.e., systemic inflammatory response syndrome criteria, sequential organ failure assessment (SOFA), or quick SOFA. These limitations have underscored the modest progress in reducing sepsis-related mortality. This review will focus on novel therapeutics such as oxidative stress targets, cytokine modulation, endothelial cell modulation, etc., that are being conceptualized for the management of sepsis and septic shock.

The care of a patient involved in major trauma with exsanguinating haemorrhage is time-critical to achieve definitive haemorrhage control, and it requires co-ordinated multidisciplinary care. During initial resuscitation of a patient in the emergency department (ED), Code Crimson activation facilitates rapid decision-making by multi-disciplinary specialists for definitive haemorrhage control in operating theatre (OT) and/or interventional radiology (IR) suite. Once this decision has been made, there may still be various factors that lead to delay in transporting the patient from ED to OT/IR. Red Blanket protocol identifies and addresses these factors and processes which cause delay, and aims to facilitate rapid and safe transport of the haemodynamically unstable patient from ED to OT, while minimizing delay in resuscitation during the transfer. The two processes, Code Crimson and Red Blanket, complement each other. It would be ideal to merge the two processes into a single protocol rather than having two separate workflows. Introducing these quality improvement strategies and coordinated processes within the trauma framework of the hospitals/healthcare systems will help in further improving the multi-disciplinary care for the complex trauma patients requiring rapid and definitive haemorrhage control.

Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.

Clavicle fractures are frequent orthopedic injuries, often resulting from direct trauma or a fall. Most clavicle fractures are treated conservatively without any complications or adverse effects. Concomitant injuries of the subclavian vein or artery are rarely encountered and most commonly associated with high-energy trauma or comminuted clavicle fractures. They are potentially life-threatening conditions leading to hemorrhage, hematoma, pseudoaneurysm or upper limb ischemia. However, the clinical presentation might be obscure and easily missed, particularly in closed and minimally displaced clavicular fractures, and timely diagnosis relies on early clinical suspicion. Currently, computed tomography angiography has largely replaced conventional angiography for the assessment of subclavian vessel patency, as it demonstrates high accuracy and temporal resolution, acute turnaround time, and capability of multiplanar reconstruction. Depending on the hemodynamic stability of the patient and the severity of the injury, subclavian vessel lesions can be treated conservatively with observation and serial evaluation or operatively. Interventional vascular techniques should be considered in patients with serious hemorrhage and limb ischemia, followed by stabilization of the displaced clavicle fracture. This review aims to provide a comprehensive overview of the incidence, clinical presentation, diagnostic approaches, and current management strategies of clavicle fractures associated with subclavian vessel injuries.

Patients in the intensive care unit (ICU) may need bedside endoscopy for gastrointestinal (GI) emergencies. Conducting endoscopy in the ICU for critically ill patients needs special consideration. This mini review focuses on indications for bedside endoscopes, including GI bleeding, volvulus, and bowel obstruction. It explains the risks associated with urgent endoscopies in critical patients and outcomes. Hemodynamic instability, coagulopathy, and impaired mucosal visualization are important considerations before bedside endoscopy. It also discusses the anesthesia considerations for non-operating room anesthesia. Multidisciplinary collaboration, meticulous patient selection, and procedural optimization help mitigate risks and maximize procedural success.