Anaesthesia and Intensive Care最新文献

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

We aimed to identify variations in nitrous oxide (N₂O) procurement between Australian states and territories per public hospital bed by undertaking a cross-sectional analysis of N₂O procurement data for all Australian public hospitals from 1 January 2017 to 30 June 2022. Data were obtained from state and territory departments of health. All Australian public hospitals across six states and two territories were included. We obtained N₂O procurement data from Department of Health representatives from all states and territories, accounting for all 697 Australian public hospitals and four public dental hospitals. The main outcome measured in this study was N₂O procurement per public hospital bed by state or territory. Across the 5 years (1 January 2017 to 30 June 2022) an average of 242,054 (standard deviation (SD) 16,222) kg of N₂O, equivalent to 64,144 (4299) tonnes of carbon dioxide emissions (CO₂e), were procured per annum. CO₂e emissions from N₂O purchase varied more than threefold per public hospital bed between different states/territories (0.47-1.48 CO₂e tonnes per hospital bed). There were significant variations in N₂O procurement between Australian states and territories when adjusted for public hospital bed numbers. Further analysis of this variation to determine cause and to guide mitigation interventions is therefore warranted.

Routine chest X-ray (CXR) post intrathoracic drain removal in cardiac surgical patients is common practice to identify the presence of a pneumothorax following drain removal. Such pneumothoraces occur infrequently and rarely require intervention. We investigated the utility of routine CXR post drain removal and hypothesised that the practice is unnecessary and a possible area for significant cost saving. We conducted a single-centre, retrospective study of 390 patients who underwent cardiac surgery over a one-year period. Routine CXR post drain removal was reviewed for the presence of a pneumothorax. Rates of intervention post routine CXR were analysed to assess for clinical benefit obtained from this practice. Potential cost savings were calculated by the cost of a mobile CXR and by considering the radiographer's time. There were 15 pneumothoraces detected on routine CXR post drain removal. All pneumothoraces detected on routine post drain removal CXR were defined as small. No patients had a clinically significant pneumothorax requiring re-insertion of a chest drain. The potential cost saved by omitting routine CXR post drain removal was estimated to be approximately A$7750 per year. This study did not detect any clinically significant pneumothoraces requiring intervention. It also suggests that routine CXR post drain removal does not provide any clinical benefit and indicates that current practice should be reviewed.

Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.

We present a case of severe taipan envenoming in northern New South Wales in a 68-year-old man. He developed severe neurotoxicity requiring intubation and ventilation, venom-induced consumption coagulopathy, myotoxicity and thrombotic microangiopathy with acute kidney injury requiring dialysis. He was administered brown and tiger snake antivenom consistent with guidelines and snake occurrence in the region. Taipan venom was detected in serum (72 ng/ml) following concern about the severity of neurotoxicity, clinical toxicology consultation and a concurrent report of a taipan in the area. Based on this it would be prudent to stock and consider treating with polyvalent antivenom in north-eastern New South Wales and south-eastern Queensland.