Anaesthesia and Intensive Care最新文献

Fibreoptic intubation (FOI) is an essential skill expected of specialist anaesthetists. With advances in alternative techniques for managing difficult airways, training opportunities for FOI have diminished. We sought to investigate the cumulative number of FOIs performed by anaesthesia trainees and assess their confidence in both independently performing and teaching FOI. An online survey was emailed to all registrars and provisional fellows working in Western Australian (WA) anaesthesia departments. There were 224 surveys sent and 100 (44.6%) respondents. The median cumulative number of FOIs was 5 (interquartile range (IQR) 0-30), with trainee registrars performing a median of 4 (IQR 0-20) and provisional fellows performing 18 (IQR 9.0-27.5) FOIs. The trainees rarely performed FOIs unsupervised, as 98.7% of trainee registrar and 88.6% of provisional fellow FOIs had level 1-2 supervision. Confidence to teach or independently perform FOI was low, even among provisional fellows. The Pearson correlation coefficient between the number of awake FOIs and confidence was 0.751. Extrapolating from these responses, the number of awake FOIs required for trainees to feel very confident in independent awake FOI was 19 (R² = 0.564, P < 0.001). Fibreoptic bronchoscopy simulator use was common (72%); however, completion of an awake fibreoptic course was low (32%). This survey found FOI among trainee and provisional fellow respondents in WA to be infrequent, and confidence to independently perform or teach an awake FOI to be low. We recommend increasing opportunities for awake FOI and implementing an advanced airway management course to help address this gap in anaesthesia training.

This case report describes the management of a patient with a lumbar arachnoid cyst requesting epidural labour analgesia. The patient was otherwise healthy but had suffered from multiple dural punctures during attempted epidural placement in a previous pregnancy. Magnetic resonance imaging following the dural punctures revealed the cyst, which was at the level of the L3-4 interspace, effacing the posterior epidural space at that level. Multidisciplinary management in this subsequent pregnancy, involving radiology and anaesthesia specialists, allowed ultrasound-guided identification of a higher epidural space, and successful and uneventful epidural placement during labour. Multiple dural punctures with attempted epidural placement should prompt anaesthetists to consider spinal magnetic resonance imaging to identify anatomical abnormalities that may be present, which may have implications for future management.

Post-procedural residual neuromuscular paralysis is an uncommon but serious complication in the general surgical population. Whilst the incidence of post-procedural residual neuromuscular paralysis in the general surgical population has been widely reported, there are no published data on the definition or incidence of this complication in patients undergoing electroconvulsive therapy (ECT). In our single-centre, prospective observational audit we studied the incidence of residual neuromuscular blockade following ECT between January and April 2021. Out of 25 procedures carried out over this time period, 23 were included for analysis. A total of 14 patients (61%) left the ECT suite with potentially clinically significant residual neuromuscular blockade. The median suxamethonium dose was 0.83mg/kg (interquartile range 0.68-0.91). Despite the known complications resulting from post-procedural residual neuromuscular blockade, neuromuscular monitoring is not mandated in guidelines published by the Australian and New Zealand College of Anaesthetists or the American Society of Anesthesiologists. Our preliminary findings suggest that further research into the scope and significance of residual neuromuscular blockade following ECT is warranted.

A woman in her early sixties presented to the emergency department with an altered level of consciousness and severe hypertension (blood pressure 197/111 mmHg) on a background of Grave's disease, osteoporosis and hypertension. She was intubated following prolonged seizure activity attributed to critical hyponatraemia (serum sodium 108 mmol/L). Abnormal renal function (estimated glomerular filtration rate 51 ml/min per 1.73m²) was also identified on admission. She was transferred to the intensive care unit for further investigation and management of hypertension and hyponatraemia, where she made an excellent recovery and a unifying diagnosis of bilateral renal artery stenosis was made. Renal artery stenosis has been previously described with chronic and unilateral presentations not requiring intensive care support. This case report describes the pathophysiology of this previously unreported presentation of severe symptomatic hyponatraemia and hypertension due to bilateral renal artery stenosis and the challenges faced in intensive care to determine the diagnosis.

Prekallikrein deficiency is a rare autosomal recessive coagulation disorder that prolongs the activated clotting time. Guidelines for safe intraoperative coagulation control in patients with prekallikrein deficiency undergoing endovascular aortic repair are limited. We present a case of a 70-year-old man with prekallikrein deficiency who underwent endovascular aortic repair and required intraoperative anticoagulation control. Intraoperative anticoagulation with heparin and protamine was successfully managed using the activated clotting time measurements after preoperative administration of two units of fresh frozen plasma for prekallikrein replenishment. Preoperative prekallikrein replenishment by fresh frozen plasma administration contributed to safe intraoperative anticoagulation management.

The preoperative risk score and key recommendations designed by the National Emergency Laparotomy Audit (NELA) have resulted in improved outcomes for patients undergoing emergency laparotomy. However, the recommended routine intensive care/high dependency unit (ICU) admission for high-risk patients is not always logistically possible and predictive models are needed to identify patients who will benefit. We conducted a study of patients undergoing emergency laparotomy at our tertiary hospital in Western Australia between 2018 and 2023 to identify factors that were associated with the need for ICU admission after emergency laparotomy, as defined by the requirement for a vasopressor infusion, continuous renal replacement therapy or ventilation. Of 1100 patients identified, 875 were included in the primary analysis. In multivariate analysis, the only independent predictive factors of the need for ICU therapies were the American Society of Anesthesiologists grade (P=0.017) and peak intraoperative serum lactate concentration >2 mmol/L (P=0.038). An increased NELA score was associated with mortality; however, it was not associated with the requirement for any ICU therapy (P=0.993). Although only 35.8% of high-risk patients were admitted to ICU, there was no apparent increase in adverse outcomes including mortality or unexpected ICU admission, and 27.4% of patients that were admitted to ICU received no specific therapies. This study provides a basis for the development of new predictive models for ICU admission post emergency laparotomy, and suggests the possibility that routine elective admission might not necessarily add value beyond that achieved by other NELA standards.

On 14 October 1846, Charles F Heywood, house-surgeon at the Massachusetts General Hospital, Boston, MA, USA, penned an invitation to the dentist William TG Morton to demonstrate his preparation to prevent pain during a surgical operation at the Hospital on 16 October 1846. The operation would become the first public operation performed with the aid of insensibility produced by the inhalation of sulphuric ether. From Boston, news of the discovery spread around the world-the date of this momentous operation is now celebrated as Ether Day. Although Heywood's letter is well-known from 19th century transcripts, it is apparent from examining a letter believed to be the original, now preserved in the WTG Morton papers held by the Massachusetts Historical Society, Boston, MA, USA, that these transcripts were edited before publication. A faithful transcript of Heywood's letter is published along with two images of the historic letter.