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Observational study of the effect of ketamine infusions on sedation depth, inflammation, and clinical outcomes in mechanically ventilated patients with SARS-CoV-2. 氯胺酮输注对机械通气SARS-CoV-2患者镇静深度、炎症及临床转归影响的观察研究
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-11-25 DOI: 10.1177/0310057X231201184
David Wyler, Marc C Torjman, Ron Leong, Michael Baram, William Denk, Sara C Long, Richard J Gawel, Eugene R Viscusi, Irving W Wainer, Eric S Schwenk

Severely ill patients with COVID-19 are challenging to sedate and often require high-dose sedation and analgesic regimens. Ketamine can be an effective adjunct to facilitate sedation of critically ill patients but its effects on sedation level and inflammation in COVID-19 patients have not been studied. This retrospective, observational cohort study evaluated the effect of ketamine infusions on inflammatory biomarkers and clinical outcomes in mechanically ventilated patients with SARS-CoV-2 infection. A total of 186 patients were identified (47 received ketamine, 139 did not). Patients who received ketamine were significantly younger than those who did not (mean (standard deviation) 59.2 (14.2) years versus 66.3 (14.4) years; P = 0.004), but there was no statistically significant difference in body mass index (P = 0.25) or sex distribution (P = 0.91) between groups. Mechanically ventilated patients who received ketamine infusions had a statistically significant reduction in Richmond Agitation-Sedation Scale score (-3.0 versus -2.0, P < 0.001). Regarding inflammatory biomarkers, ketamine was associated with a reduction in ferritin (P = 0.02) and lactate (P = 0.01), but no such association was observed for C-reactive protein (P = 0.27), lactate dehydrogenase (P = 0.64) or interleukin-6 (P = 0.87). No significant association was observed between ketamine administration and mortality (odds ratio 0.971; 95% confidence interval 0.501 to 1.882; P = 0.93). Ketamine infusion was associated with improved sedation depth in mechanically ventilated COVID-19 patients and provided a modest anti-inflammatory benefit but did not confer benefit with respect to mortality or intensive care unit length of stay.

COVID-19重症患者很难镇静,通常需要大剂量镇静和镇痛方案。氯胺酮可有效辅助重症患者镇静,但其对COVID-19患者镇静水平和炎症的影响尚未研究。这项回顾性、观察性队列研究评估了氯胺酮输注对机械通气的SARS-CoV-2感染患者炎症生物标志物和临床结局的影响。共确定186例患者(47例接受氯胺酮治疗,139例未接受氯胺酮治疗)。接受氯胺酮治疗的患者明显比未接受氯胺酮治疗的患者年轻(平均(标准差)59.2(14.2)岁对66.3(14.4)岁;P = 0.004),但两组间体重指数(P = 0.25)和性别分布(P = 0.91)差异无统计学意义。接受氯胺酮输注的机械通气患者的Richmond激动-镇静量表评分降低具有统计学意义(-3.0 vs -2.0, P 0.001)。在炎症生物标志物方面,氯胺酮与铁蛋白(P = 0.02)和乳酸(P = 0.01)的减少有关,但与c反应蛋白(P = 0.27)、乳酸脱氢酶(P = 0.64)或白细胞介素-6 (P = 0.87)的减少没有关联。氯胺酮给药与死亡率无显著相关性(比值比0.971;95%置信区间0.501 ~ 1.882;p = 0.93)。氯胺酮输注与机械通气的COVID-19患者镇静深度的改善有关,并提供适度的抗炎益处,但在死亡率或重症监护病房住院时间方面没有益处。
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引用次数: 0
A weighing method for measuring nitrous oxide leakage from hospital manifold-pipeline networks. 一种测量医院歧管管网氧化亚氮泄漏的称重方法。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-11-25 DOI: 10.1177/0310057X231198123
Steven J Gaff, Victor X Chen, Eugenie Kayak

Nitrous oxide is a potent greenhouse gas and ozone-depleting agent with a long atmospheric lifetime. Several previous reports indicate that over half of supplied nitrous oxide is wasted from leaking manifold-pipeline systems infrastructure prior to patient use, and that remediating leaks can have significant environmental benefits. We describe an accurate, simple and cost-effective cylinder weighing method to quantify nitrous oxide leak from the manifold-pipeline network at our tertiary non-obstetric facility. Nitrous oxide cylinder depletion was prospectively compared with clinical usage derived from the electronic medical record over an 18-day period. A total of 1932 l (3.62 kg) of nitrous oxide was used in 35 operating theatre cases during the period. This was only 16.5% of actual cylinder depletion (11,686 l; 21.88 kg), indicating that 83.5% (9754 l; 18.26 kg) of nitrous oxide had leaked to the atmosphere (376 ml/minute; 22.6 l/hour; 542 l/day). The fraction of nitrous oxide wasted was consistent with a retrospective analysis of the previous 2-year period at the site that compared purchasing records with estimated clinical use. If maintained over a year, the leak would be equivalent to 101 tonnes of carbon dioxide per annum.

一氧化二氮是一种强效的温室气体和臭氧消耗剂,具有很长的大气寿命。先前的几份报告表明,在患者使用之前,超过一半的供应氧化亚氮被浪费在泄漏的歧管管道系统基础设施中,并且修复泄漏可以带来显着的环境效益。我们描述了一种准确,简单和具有成本效益的钢瓶称重方法,以量化一氧化二氮泄漏从我们的三级非产科设施的歧管管网。在18天的时间内,前瞻性地比较了一氧化二氮气瓶耗竭与来自电子病历的临床使用情况。在此期间,共在35个手术室病例中使用了1932 l (3.62 kg)氧化亚氮。这仅仅是实际汽缸损耗的16.5% (11,686 l;21.88 kg),表示83.5% (9754 l;18.26千克的一氧化二氮泄漏到大气中(每分钟376毫升;22.6升/小时;542升/天)。一氧化二氮浪费的比例与该地点前2年期间的回顾性分析一致,该分析将采购记录与估计的临床使用进行了比较。如果维持一年以上,泄漏量将相当于每年101吨二氧化碳。
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引用次数: 0
Percutaneous electrical nerve stimulation in post-mastectomy neuropathic pain: A case report. 经皮神经电刺激治疗乳房切除术后神经性疼痛1例。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-12-02 DOI: 10.1177/0310057X231199800
Gary W Wong, Akhilesh K Tiwari

Post-mastectomy pain syndrome (PMPS) is a type of chronic postsurgical pain that can be severe, debilitating and frequently encountered in clinical practice. Multiple studies have focused on prevention, identifying risk factors and treating this condition. Nonetheless, PMPS remains a complex condition to treat effectively. In this case report, we describe the use of percutaneous electrical nerve stimulation in a breast cancer patient who experienced PMPS refractory to conventional treatments.

乳房切除术后疼痛综合征(PMPS)是一种慢性术后疼痛,可能是严重的,使人虚弱,在临床实践中经常遇到。多项研究都集中在预防、识别风险因素和治疗这种疾病上。尽管如此,经前症候群仍然是一种难以有效治疗的复杂病症。在这个病例报告中,我们描述了使用经皮神经电刺激的乳腺癌患者谁经历了难治性PMPS传统治疗。
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引用次数: 0
Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review. 区域麻醉下眼科手术后视网膜动脉闭塞:叙述回顾。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-12-02 DOI: 10.1177/0310057X231215826
Alfred Wy Chua, Matthew J Chua, Brian P Harrisberg, Chandra M Kumar

Two recent cases of central retinal artery occlusion under otherwise uncomplicated sub-Tenon's block that resulted in significant visual loss after cataract surgery prompted us to undertake a literature review of such cases. We identified 97 cases of retinal artery occlusion after ophthalmic surgery under regional anaesthesia that had no immediate signs of block-related complications. These occurred after various intraocular (87%) and extraocular (13%) operations, across a wide range of ages (19-89 years) on patients with (59%) or without (39%) known risk factors. The anaesthetic techniques included 40 retrobulbar blocks, 36 peribulbar blocks, 19 sub-Tenon's blocks, one topical anaesthetic and one unspecified local anaesthetic. Different strengths of lidocaine, bupivacaine, mepivacaine and ropivacaine, either alone or in various combinations, were used. The details of the anaesthetic techniques were often incomplete in the reports, which made comparison and analysis difficult. Only nine cases had their cause (optic nerve sheath injury) identified, while the mechanism of injury was unclear in the remaining patients. Various mechanisms were postulated; however, the cause was likely to be multifactorial due to patient, surgical and anaesthetic risk factors, especially in those with compromised retinal circulation. As there were no definite risk factors identified, no specific recommendations could be made to avoid this devastating outcome. We have provided rationales for some general considerations, which may reduce this risk, and propose anaesthetic options for ophthalmic surgery on the fellow eye if required, based both on our literature review and our personal experience.

最近的两例视网膜中央动脉闭塞,在其他情况下并不复杂,导致白内障手术后明显的视力丧失,促使我们对这类病例进行文献回顾。我们确定了97例视网膜动脉闭塞的眼科手术后,在区域麻醉下,没有立即的迹象,阻塞相关的并发症。这些发生在各种眼内(87%)和眼外(13%)手术后,年龄范围广(19-89岁),有(59%)或无(39%)已知危险因素的患者。麻醉技术包括40个球后阻滞,36个球周阻滞,19个球下阻滞,1个局部麻醉和1个未指明的局部麻醉。使用不同剂量的利多卡因、布比卡因、甲哌卡因和罗哌卡因单独使用或以不同的组合使用。麻醉技术的细节在报告中往往不完整,这给比较和分析带来了困难。只有9例患者的病因(视神经鞘损伤)被确定,而其余患者的损伤机制尚不清楚。假设了各种机制;然而,原因可能是多因素的,由于患者,手术和麻醉的危险因素,特别是在那些视网膜循环受损。由于没有确定明确的风险因素,因此无法提出具体建议来避免这种毁灭性的后果。我们提供了一些一般考虑的理由,这可能会降低这种风险,并根据我们的文献综述和我们的个人经验,在必要时对另一只眼睛进行眼科手术时提出麻醉选择。
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引用次数: 0
Bronchial blockers: Has side-by-side fallen by the wayside? Not quite. 支气管阻滞剂:肩并肩已经被淘汰了吗?不完全是。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-12-02 DOI: 10.1177/0310057X231202812
Blake J Vorias, Nicholas J Barton, Desmond P McGlade, Naveed Alam
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引用次数: 0
Does gender still matter in the pursuit of a career in anaesthesia? 在追求麻醉学的职业生涯中,性别仍然重要吗?
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-03-01 Epub Date: 2023-11-25 DOI: 10.1177/0310057X231212210
Claire H Stewart, Jane Carter, Natalie Purcell, Maryanne Balkin, Julia Birch, Greta C Pearce, Timothy Makar

A survey sent to fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) aimed to document issues affecting gender equity in the anaesthesia workplace. A response rate of 38% was achieved, with women representing a greater proportion of respondents (64.2%). On average women worked fewer hours than men and spent a larger percentage of time in public practice; however, satisfaction rates were similar between genders. There was a gender pay gap which could not be explained by the number of hours worked or years since achieving fellowship. The rates of bullying and harassment were high among all genders and have not changed in 20 years since the first gender equity survey by Strange Khursandi in 1998. Women perceived that they were more likely to be discriminated against particularly in the presence of other sources of discrimination, and highlighted the importance of the need for diversity and inclusion in anaesthetic workplaces. Furthermore, women reported higher rates of caregiving and unpaid domestic responsibilities, confirming that anaesthetists are not immune to the factors affecting broader society despite our professional status. The overall effect was summarised by half of female respondents reporting that they felt their gender was a barrier to a career in anaesthesia. While unable to be included in statistics due to low numbers, non-binary gendered anaesthetists responded and must be included in all future work. The inequities documented here are evidence that ANZCA's gender equity subcommittee must continue promoting and implementing policies in workplaces across Australia and New Zealand.

一项发给澳大利亚和新西兰麻醉师学院(ANZCA)研究员的调查旨在记录影响麻醉工作场所性别平等的问题。达到38%的回复率,其中女性占更大比例(64.2%)。平均而言,女性的工作时间比男性短,在公共实践中花费的时间比例更高;然而,男女之间的满意度是相似的。男女薪酬差距不能用工作时数或获得研究金后的年数来解释。在所有性别中,欺凌和骚扰的比例都很高,自1998年斯特兰奇·库尔桑迪(Strange Khursandi)首次进行性别平等调查以来,这一比例在20年里没有改变。妇女认为,她们更有可能受到歧视,特别是在存在其他歧视来源的情况下,并强调麻醉工作场所需要多样化和包容性的重要性。此外,据报告,妇女承担照顾和无偿家务责任的比例更高,这证实,尽管麻醉师的职业地位很高,但他们也不能幸免于影响更广泛社会的因素。总的来说,有一半的女性受访者表示,她们觉得自己的性别是从事麻醉职业的障碍。虽然由于人数少而无法纳入统计,但非二元性别麻醉师做出了回应,并且必须纳入所有未来的工作。这里记录的不平等证明了澳新会性别平等小组委员会必须继续在澳大利亚和新西兰的工作场所促进和实施政策。
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引用次数: 0
Prevention of airway fires during tracheostomy is preferable. Comment on: Simulation training results in performance retention for the management of airway fires: A prospective observational study. 气管造口术期间最好预防气道火灾。评论:模拟训练在气道火灾管理中的成绩保持:一项前瞻性观察性研究。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-01-01 Epub Date: 2023-10-06 DOI: 10.1177/0310057X231196908
Kar-Soon Lim
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引用次数: 0
Metabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report. 枫糖浆尿病的代谢危机:罕见疾病的罕见并发症:1例报告。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-01-01 Epub Date: 2023-11-23 DOI: 10.1177/0310057X231183981
Hemang P Doshi, Hemal H Vachharajani, Michael C Tchan, Mohamed A Nasreddine, Kate E Billmore

A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.

一名患有枫糖浆尿病的19岁女性在甲型流感感染和难治性呕吐的情况下出现代谢危像,迅速发展为急性脑水肿,表现为难治性癫痫发作和意识水平下降,需要紧急插管和机械通气,持续静脉-静脉血液扩张滤过和硫喷酮昏迷。大脑的计算机断层扫描和磁共振成像显示了代谢紊乱引起的代谢危机继发的脑水肿的典型征象。由于缺乏在成人重症监护环境中管理这种临床场景的熟悉度和经验,她的管理给所有相关团队带来了多重挑战。
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引用次数: 0
The introduction of blood gases into clinical practice. 将血气引入临床实践。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-01-01 DOI: 10.1177/0310057X231212299
Christine M Ball, Peter J Featherstone
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引用次数: 0
Risk factors for mortality in severe COVID-19: Exploring the interplay of immunomodulatory therapy and coinfection. 重症 COVID-19 患者死亡的风险因素:探索免疫调节疗法与合并感染的相互作用。
IF 1.5 4区 医学 Q3 ANESTHESIOLOGY Pub Date : 2024-01-01 Epub Date: 2023-09-17 DOI: 10.1177/0310057X231183451
Annaleise R Howard-Jones, Stephen Huang, Sam R Orde, James M Branley

Patients with severe clinical manifestations of coronavirus disease 2019 (COVID-19) present particular diagnostic and management challenges to critical care physicians, including identifying and responding to concurrent bacterial and fungal coinfections. This study evaluates risk factors for in-hospital mortality in patients admitted to the intensive care unit with severe COVID-19 during circulation of the B.1.617.2 (Delta) variant, including the impact of immunomodulators and bacterial and/or fungal coinfection. This retrospective cohort study enrolled patients with severe COVID-19. A Cox proportional hazard ratio analysis identified risk factors for in-hospital mortality. Outcomes were also compared between patients receiving and not receiving immunomodulatory therapy alongside standard care. Ninety patients admitted to the intensive care unit were enrolled. On multivariate analysis, the greatest risk factors for in-hospital mortality were invasive mechanical ventilation (hazard ratio (HR) = 15.27; 95% confidence interval (CI) 3.29-71.0; P < 0.001), elevated body mass index (HR = 1.07 per unit; 95% CI 1.02-1.13; P = 0.007) and older age (HR = 1.53 per decade; 95% CI 1.05-2.24; P = 0.028). Bacterial and/or fungal coinfection occurred at equal frequency in patients receiving and not receiving immunomodulatory therapy. However, in patients receiving immunomodulators, coinfection carried a significantly higher mortality risk (63.0%) compared with those without coinfection (15.4%; P = 0.038). Mortality from severe COVID-19 is significantly higher in older patients and those with elevated body mass index and requiring mechanical ventilation. Immunomodulatory therapy necessitates vigilance towards evolving coinfection in the intensive care setting.

临床表现严重的冠状病毒病2019(COVID-19)患者给重症监护医生带来了特殊的诊断和管理挑战,包括识别和应对并发的细菌和真菌合并感染。本研究评估了在B.1.617.2(Delta)变异体循环期间因重症COVID-19入重症监护病房的患者院内死亡的风险因素,包括免疫调节剂和细菌和/或真菌合并感染的影响。这项回顾性队列研究招募了严重COVID-19患者。Cox比例危险比分析确定了院内死亡率的风险因素。研究还比较了在接受标准护理的同时接受和不接受免疫调节疗法的患者的治疗结果。重症监护室收治的 90 名患者参加了此次研究。通过多变量分析,院内死亡的最大风险因素是侵入性机械通气(危险比 (HR) = 15.27;95% 置信区间 (CI) 3.29-71.0;P = 0.007)和年龄(HR = 每十年 1.53;95% CI 1.05-2.24;P = 0.028)。接受和未接受免疫调节疗法的患者发生细菌和/或真菌合并感染的频率相同。然而,在接受免疫调节剂治疗的患者中,合并感染带来的死亡风险(63.0%)明显高于未合并感染的患者(15.4%;P = 0.038)。在老年患者、体重指数升高和需要机械通气的患者中,严重 COVID-19 的死亡率明显更高。免疫调节疗法需要对重症监护环境中不断演变的合并感染保持警惕。
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引用次数: 0
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Anaesthesia and Intensive Care
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