Anaesthesia reports最新文献

Head and neck trauma can result in difficult airway management. A 25-year-old male required emergency tracheal intubation on arrival to the emergency department following a motorbike accident. Despite the presence of a normal capnography a computed tomography scan demonstrated a tracheal opening, an extra-tracheal position of the distal end of the tracheal tube, and extensive subcutaneous emphysema. The tube was re-directed into the trachea and the tracheal injury was surgically repaired. This case highlights that the presence of a normal capnograph does not necessarily mean that the distal end of the tracheal tube resides within the airway.

A 26-year-old man underwent retroperitoneal lymph node dissection following diagnosis of non-seminomatous testicular germ cell tumour. He had previously undergone an inguinal orchidectomy. The surgery was performed under general anaesthesia with thoracic epidural for analgesia. Four hours after the start of surgery, tachycardia and hypotension developed which did not respond to fluid therapy. Therefore, intravenous noradrenaline infusion was started at a rate of 0.01–0.07 μg.kg⁻¹.min⁻¹ which was discontinued 2 h after surgery. During the operation, both arms were abducted to 90 degrees. At the end of the surgery, the patients' trachea was extubated and he was transferred to the intensive care unit. On the first postoperative day, the patient developed a left upper limb monoparesis without sensory deficit. Magnetic resonance imaging (MRI) of the brain and brachial plexus were undertaken. The MRI brain revealed a haemorrhagic lesion with surrounding oedema, leading to a diagnosis of symptomatic intratumoural bleed with raised intracranial pressure (Fig. 1). This was suspected to be a metastatic lesion as it was well-defined and solitary. Testicular tumours can metastasise to the brain, although this is rare. The patient was treated with intravenous dexamethasone and received targeted radiotherapy which led to complete recovery of the arm weakness by postoperative day 21.

Brain metastases in non-seminomatous testicular germ cell tumours are uncommon, but more likely to occur in those over 40, with elevated levels of β-human chorionic gonadotropin (≥ 5000 IU.l⁻¹) and alpha-fetoprotein (> 10,000 ng.ml⁻¹), pulmonary or bone metastases, and neurological symptoms. Due to the absence of these symptoms and low tumour marker levels, pre-operative brain imaging was not performed in this case [1, 2]. The tumour markers were repeated and were within normal range.

In non-seminomatous testicular germ cell tumours, spontaneous tumour bleed is rare, and while the patient's coagulation profile and platelets were normal, systemic immune response syndrome and immune suppression may have contributed to the bleeding risk. Systemic immune response syndrome may lead to increased metabolism and vascular complications, possibly influencing the occurrence of intratumoural bleeding [3, 4].

For us, the key point is that brain metastases can mimic anaesthetic complications, such as brachial plexus injury or a cerebrovascular accident. This highlights the need for a comprehensive differential diagnosis in the postoperative period to ensure accurate identification and management of underlying conditions.

We report the case of a 61-year-old female who developed heparin-induced thrombocytopaenia following treatment of a submassive pulmonary embolism, and who then required an above knee amputation for critical limb ischaemia. Heparin-induced thrombocytopaenia is a rare, immune-mediated complication associated with an in-hospital mortality rate of 10%. It is more common in surgical patients, with patients undergoing orthopaedic surgery more likely to develop it than patients undergoing cardiac surgery, but heparin-dependent immunoglobulin G antibodies are more likely to be formed in the latter. Peri-operative management remains a challenge. Ideally, it is preferable to wait for the platelet count to improve; but in certain cases, surgery cannot be delayed. Heparin-induced thrombocytopaenia is usually managed with direct thrombin inhibitors, such as argatroban and bivalirudin. Newer therapeutic modalities, such as plasmapheresis and intravenous immunoglobulin, as used in this case, can rapidly remove antibodies, but the certainty of evidence is low. Our case adds to the literature regarding the use of these modalities and highlights the multidisciplinary team approach required to manage such complex cases.

The National Tracheostomy Safety Project has run high-quality, face-to-face skills courses since 2009. The aim of this project was to produce a virtual reality version of the established course and evaluate its impact on participant learning, and participant and faculty satisfaction. Healthcare staff and students were recruited and randomised to attend one of (1) a face-to-face traditional course (control); (2) a virtual reality course at a conference centre with on-site technical support; (3) a fully remote virtual reality course; the virtual reality groups were combined for the analysis of learning outcomes and satisfaction. The primary outcome was the difference in pre/post-course knowledge scores on a 30-item questionnaire; secondary outcomes included knowledge retention, usability, comfort/side effects and participant performance in a simulated tracheostomy emergency. Thirty-seven participants and 15 faculty participated in this study. There was no significant difference between mean pre/post-course scores from the face-to-face (from 21.1 to 23.1; +2) and combined virtual reality (from 17.1 to 21.1; +4) groups, with both showing improvement (p = 0.21). The mean System Usability Scale score for virtual reality was 76.8 (SD 12.6), which is above average; the median Simulator Sickness Questionnaire score was 7.5 (IQR 3.7–22.4), indicating minimal symptoms. All participants resolved the primary clinical problem in the simulated emergency, but the virtual reality (VR) group was slower overall (mean difference 61.8 s, p = 0.003). This technical feasibility study demonstrated that there was no difference in participant knowledge immediately after and 4 weeks following face-to-face and virtual reality courses. Virtual reality offers an immersive experience that can be delivered remotely and offers potential benefits of reducing travel and venue costs for attendees, therefore increasing the flexibility of training opportunities.