Anaesthesia and Intensive Care最新文献

While both considered rare in contemporary Australian anaesthetic practice, the symptoms of epidural complication can mimic those of spinal tuberculosis, as we outline here in this unusual case. A 33-year-old woman presented to hospital with new neurological deficits days after receiving a lumbar epidural for labour analgesia. A complication of epidural was initially suspected; however, spinal tuberculosis was found be the cause. This case demonstrates many of the challenges and unique requirements involved in providing neuraxial anaesthesia to the obstetric cohort, namely: consenting linguistically diverse patients, providing advice on discharge, and the role of anaesthetics in expediting time-critical investigations.

Postoperative pain management in breast cancer surgery remains challenging, particularly in procedures involving submammary tissue expander placement, where patients often report inadequate pain control. The complex innervation of the breast region, involving intercostal nerves (T2-T6), brachial plexus branches, and supraclavicular nerves (C3-C4), necessitates comprehensive anaesthetic coverage. We present four cases utilising a novel combined approach of erector spinae plane (ESP) and serratus posterior superior interfascial plane (SPSIP) blocks for perioperative pain management. The technique involves ultrasound-guided administration of ropivacaine 0.25% (20 ml for each block) targeting the T3 level for ESP and the fascial plane between the second and third ribs for SPSIP. This combination provides extensive hemithoracic analgesia from C3 to T10, potentially covering both superficial and deep tissue components of surgical pain. Our cases demonstrated excellent postoperative pain control with minimal analgesic requirements. The proximity of injection sites allows efficient block performance without patient repositioning. This additive approach shows promise in achieving comprehensive analgesia for breast surgery, including cases involving tissue expanders, though larger targeted studies are needed to confirm these preliminary findings.

Microcirculatory failure is recognised as a critical pathophysiological factor in the development of multi-organ failure in critically ill patients. However, traditional resuscitative efforts have focused on macrohaemodynamic variables such as blood pressure and cardiac output. These parameters may be insensitive for detecting changes in tissue perfusion when haemodynamic coherence is disturbed in states of shock. Several clinical studies using direct visualisation of the microcirculation have revealed that microcirculatory abnormalities can persist despite optimised global haemodynamic parameters. These abnormalities are independently associated with increased mortality. As the goal of resuscitation is to restore tissue perfusion, and the microcirculation closely reflects perfusion at the tissue level, interest in the microcirculation has grown over the years. Technological advances now allow direct observation and measurement of the microcirculation. This narrative review explores the current understanding of the microcirculation and its role in critical illness, with an overview of microcirculatory monitoring and its utility in clinical decision making.

Background: Dyskalaemias have been reported as an independent prognostic factor for adverse outcomes based on plasma potassium levels upon intensive care unit (ICU) admission or mean potassium levels across ICU stay, but the granular effects of discrete episodes of dyskalaemia have not been extensively studied.

Methods: This retrospective observational cohort study included all adult patients admitted to ICUs in public hospitals in Hong Kong between January 2010 and June 2023. Discrete episodes of dyskalaemia were defined if plasma potassium measurements were beyond the reference range of 3.5-5 mmol/l. Patients were classified into four groups based on the potassium levels throughout their ICU stay (normokalaemic, hyperkalaemic, hypokalaemic and mixed dyskalaemic). Patients with prolonged ICU length of stay beyond 14 days were excluded. The main study outcomes were ICU mortality and the incidence of arrhythmias, which was defined based on a pharmacological surrogate of requiring amiodarone between the onset of the dyskalaemic episode and ICU discharge.

Results: A total of 167,449 patients were included. A total of 60,953 (36.4%) patients remained normokalaemic. There were 21,820 (13.0%), 79,312 (47.4%) and 5364 (3.2%) patients in the hyperkalaemic, hypokalaemic and mixed dyskalaemic groups respectively. Dyskalaemia was significantly associated with increased ICU mortality (hyperkalaemia: adjusted odds ratio (aOR) 1.95, 95% confidence interval (CI) 1.79 to 2.12, P < 0.0001 vs hypokalaemia: aOR 1.83, 95% CI 1.70 to 1.96, P < 0.0001 vs mixed dyskalaemia: aOR 2·87, 95% CI 2.57 to 3.20, P < 0.0001). The same adverse effects of dyskalaemia were also observed in incidence of arrhythmias.

Conclusions: Having dyskalaemic episodes during the ICU stay was significantly associated with increased odds of ICU mortality and arrhythmias.

Desflurane is a potent and expensive greenhouse gas. Reducing its use is a global priority. This anaesthetist-led quality improvement project involved educational, motivational and system-change initiatives implemented in the anaesthesia department of Bankstown-Lidcombe Hospital (BLH) (September 2021-March 2024), with the aim of reducing desflurane consumption. A quasi-experimental interrupted time series design with control site was employed to estimate changes in usage, greenhouse gas emissions and financial cost of anaesthetic agents per 100 surgeries. Prior to intervention, use of desflurane at BLH was stable. During and after intervention, a significant downward trend in desflurane use was observed, reducing by an average of 0.1 units (1 unit = 1 bottle) per month per 100 surgeries from September 2021 onwards (95% confidence interval (CI) -0.21 to -0.01, P = 0.035). The intervention, while not directly targeting sevoflurane use, was similarly associated with a downward trend in sevoflurane usage of an average of 0.5 units per month per 100 surgeries from September 2021 onwards (95% CI -189.74 kg to -10.43 kg, P = 0.004). No significant changes in use of desflurane or sevoflurane were observed at the control site, although use of both agents declined slightly over the study period. Estimated CO₂ equivalent (CO₂e) emissions were reduced by an average of 124.7 kg per month per 100 surgeries from September 2021 onwards (95% CI -223.3 kg to -26.1 kg, P = 0.018). Average monthly cost per 100 surgeries at BLH reduced by AU$100.34 per month (95% CI -AU$162.58 to -AU$38.10, P = 0.003). There were no changes in CO₂e emissions or costs at the control site. A clinician-led intervention highlights the importance of creating opportunity and motivation for change amongst staff as well as ongoing education, advocacy and engagement with department and executive to achieve positive environmental and financial outcomes.