Anaesthesia reports最新文献

A rotational thromboelastometry (ROTEM^®) guided transfusion strategy for obstetrics was implemented at our institution in September 2022. The aim of the strategy was to facilitate timely, targeted administration of coagulation products based on viscoelastic haemostatic testing, thereby reducing unnecessary transfusions. To improve compliance with the ROTEM^® strategy, an electronic decision tool was developed and integrated into a smartphone application, supported by departmental education and training. We subsequently analysed data on 944 women who experienced postpartum haemorrhage ≥ 1500 ml over a 5-year period, comparing 1 year of data after the formal introduction of the ROTEM^®-guided transfusion strategy (post-ROTEM^®) with the previous 4 years, when a conventional transfusion strategy was in place based on standard laboratory tests (pre-ROTEM^®). Following implementation, the annual use of fibrinogen concentrate, Octaplas^® (Octapharma Pharmazeutika GmbH, Vienna, Austria) and platelets to treat PPH ≥ 1500 ml decreased by 46%, 72% and 79%, respectively, yielding a cost saving of €51,738. Compliance with evidence-based fibrinogen transfusion triggers improved significantly (84% vs. 23%) and empirical product use was eliminated. There was no statistically significant difference in the proportion of women who progressed to severe haemorrhage (≥ 2000 ml) between groups: 97/238 (40%) in the post-ROTEM^® group vs. 312/706 (44%) in the pre-ROTEM group (p = 0.35). This quality improvement initiative demonstrated that embedding a ROTEM^®-guided transfusion strategy into clinical workflows, supported by a decision tool and staff training, can enhance adherence to evidence-based practice, reduce unnecessary coagulation product use and generate substantial cost savings, without adversely affecting clinical outcomes. These findings may inform institutions seeking to optimise transfusion strategies in obstetric haemorrhage through structured implementation approaches.

Heart failure is a major peri-operative risk factor associated with significant postoperative morbidity and mortality. Traditional biomarkers used in heart failure management include natriuretic peptides. Carbohydrate antigen 125 biomarker is well known to be elevated in ovarian cancer but can also be elevated in heart failure, particularly right-sided heart failure and heart failure with preserved ejection fraction. We report the management of a 71-year-old woman with a presumed diagnosis of ovarian cancer based on imaging and an elevated carbohydrate antigen 125, who underwent cardiopulmonary exercise testing as part of the pre-operative assessment. Exercise testing, despite being sub-maximal, identified significant but asymptomatic heart failure. Surgery was deferred and cardiology-led optimisation resulted in normalisation of her carbohydrate antigen biomarker, refuting her ovarian cancer diagnosis and avoidance of a major intra-abdominal surgery. This case highlights the role of biomarkers, such as carbohydrate antigen 125, in heart failure treatment and the use of exercise testing in heart failure diagnosis and management. Cardiopulmonary exercise testing facilitated the identification of hidden comorbidities leading to better pre-operative risk stratification, optimisation and collaborative decision making.

Catheter entrapment is a rare complication of pulmonary artery catheter (PAC) insertion [1, 2].

A 57-year-old man underwent ascending aortic replacement. A PAC was inserted via the right internal jugular vein without difficulty under continuous transoesophageal echocardiographic guidance, which confirmed its appropriate placement in the right pulmonary artery. As this was his second cardiac surgery, dense adhesions were present. During adhesiolysis, an injury occurred at the base of the pulmonary artery, which was successfully repaired using felt-reinforced sutures.

Fresh blood was observed around the optical module connector upon arrival to the intensive care unit, though the significance of this was unknown (Fig. 1A). Pulmonary artery pressures, mixed venous oxygen saturation and cardiac output measurements were unaffected and clinically appropriate.

On postoperative day 1, PAC removal was attempted but resistance was encountered after withdrawing approximately 5 cm. Fluoroscopy revealed that the catheter tip was fixed. During resternotomy, we found the PAC had been inadvertently sutured to the pulmonary artery. The catheter was carefully released and removed with cardiac bypass support. Examination revealed suture punctures through the optical module lumen, resulting in blood leakage without affecting monitored values (Fig. 1B and C). The patient recovered without further complications.

Blood leakage from the optical module connector may indicate catheter damage or entrapment, even in the absence of abnormal monitoring data, and should prompt further evaluation.

A 32-year-old woman presented with transient visual loss following the intra-operative administration of a single intravenous dose of tranexamic acid during urgent cholecystectomy. Apart from obesity, the patient had no notable medical history or pre-existing ocular conditions. Immediately after surgery, the patient reported sudden onset blindness. Ophthalmological and radiologic assessments did not reveal any detectable macrovascular or organic ophthalmic lesions. The patient's vision gradually improved spontaneously, with the resolution of the dyschromatopsia on the first postoperative day and complete recovery by the second postoperative day. This case highlights the importance of prompt investigation of acute visual impairment postoperatively and identifying potential causative agents, such as tranexamic acid.

Malignant hyperthermia is a potentially fatal autosomal dominant hypermetabolic pharmacogenetic syndrome resulting from altered intracellular calcium dynamics in skeletal muscle, triggered by halogenated anaesthetics and suxamethonium. Current evidence suggests a degree of association between malignant hyperthermia and joint dislocations. We evaluated 162 patients with a personal or family history of malignant hyperthermia utilising a standardised protocol. We found a significantly higher incidence of joint dislocations in patients with malignant hyperthermia compared to non-susceptible patients (11% versus 0%, p = 0.002). This study contributes to understanding the long-term clinical manifestations of malignant hyperthermia and consequently may help develop clinical management strategies which incorporate the risk of joint dislocations, such as care in positioning during anaesthesia, and therapeutic interventions to improve quality of life.

Karmakar A, Khan MJ, Shallik NAH, et al. Right trace wrong place: a normal capnography trace despite the tip of the tracheal tube existing outside the airway. Anaesthesia Reports 2024; 12: e12313. https://doi.org/10.1002/anr3.12313

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Hamad Medical Corporation Open Access publishing facilitated by the Qatar National Library, as part of the Wiley Qatar National Library agreement.

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