Anaesthesia and Intensive Care最新文献

An early administration of anaesthesia for childbirth occurred on 19 January 1847, when Scottish obstetrician James Young Simpson administered diethyl ether to facilitate the delivery of a child to a woman with a deformed pelvis. Simpson advocated for its use to reduce pain both in surgery and in childbirth. Obstetric anaesthesia was controversial for many reasons, and objections came not only from fellow obstetricians, but also from the public and members of the clergy. While James Young Simpson shed light upon religious objections to obstetric anaesthesia, modern scholars have debated whether such objections truly existed. The aim of this study is to determine whether religious objections to obstetric anaesthesia were endorsed by medical professionals in France during the mid-19th century. A search of the Bibliothèque Nationale de France (National Library of France) was conducted. Primary source documents reveal that French physicians were interested in studying the effects of ether and chloroform during labour and delivery. Nevertheless, the introduction of obstetric anaesthesia was controversial for many reasons, including concerns about its effect on natural labour. The evidence suggests that these objections were not endorsed by the medical community. Much of the controversy surrounding obstetric anaesthesia involved the perceived necessity of the practice during low-risk vaginal deliveries. It appears that French physicians were aware of religious objections to the use of anaesthesia in childbirth but did not endorse them. The use of obstetric anaesthesia in France was guided by scientific evidence and clinical experience, without interference from religious leaders.

Sleep, dreams, unconsciousness and death are concepts regularly contended with by anaesthetists and their patients. The closely related genealogy of the entities personifying these concepts in ancient Greek mythology highlights a visceral uncertainty about the spectrum of human unconsciousness. Hypnos and Thanatos-Sleep and Death, respectively-commonly feature together in art and literature as twin brothers. Sleep was the more powerful of the two and was feared even by members of the Pantheon immune to death such as Zeus himself, drawing a parallel with the modern knowledge that all living organisms demonstrate susceptibility to anaesthesia. The power to induce sleep was regarded as a divine ability and was thus the domain of the gods. However, some mortals possessed these talents, usually through application of herbs or potions, highlighting an understanding that a state of unconsciousness could be induced by elements from the environment in the hands of a skilled or gifted operator. Through multiple different tales, the ancient Greeks also imply a distinction between physiological and drug-induced sleep, the latter of which is frequently associated with wrath and amnesia. Despite this distinction, sleep is commonly used interchangeably with general anaesthesia in discussions with patients. Though presumably intentioned to provide reassurance, using inaccurate terminology may impact on patients' ability to make an informed decision about receiving an anaesthetic. Perhaps there is a role for artistic and allegorical methods of communication to reflect this distinction to patients as we guide them through an odyssey of their own into a state of controlled unconsciousness.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used for the treatment of type 2 diabetes and/or obesity. The physiological actions of endogenous GLP-1, and synthetic GLP-1RAs include inhibition of gastric emptying. This has peri-procedural implications due to the potential increased risk of retained gastric contents which may result in pulmonary aspiration. There is a need for local evidence-based guidelines to best manage patients on GLP-1RAs and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonists (GLP-1/GIPRAs) presenting for surgical and medical procedures requiring sedation or anaesthesia. A panel of experts was formed to consider the peri-procedural implications of GLP-1RA and GLP-1/GIPRA use and establish best practice recommendations based on the current evidence.We recommend that all patients should be asked about glucagon-like peptide-1 receptor agonist (GLP-1RA) and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonist (GLP-1/GIPRA) use prior to anaesthesia or sedation for surgical and endoscopic procedures and be informed of the benefits and risks. We also recommend that GLP-1RAs and GLP-1/GIPRAs be continued in the peri-procedural period. Preprocedural diet modification with a 24-h clear fluid diet, followed by standard 6-h fasting, should be recommended for all patients receiving GLP-1RAs or GLP-1/GIPRAs. In patients who have not completed or are unable to have a 24-h liquid diet, risk stratification using gastric ultrasound or minimally sedated gastroscopy to assess gastric contents is recommended, as is the use of intravenous erythromycin. We cannot currently recommend using the absence of gastrointestinal symptoms for risk stratification, nor can we recommend an adequate cessation period for GLP-1RAs and GLP-1/GIPRAs to ensure gastric emptying has returned to baseline levels. This clinical guideline, developed by multiple professional bodies, outlines current best practice recommendations for patients taking GLP-1RAs and combined GLP-1/GIPRAs who require general anaesthesia, sedation and/or endoscopic procedures. The guide provides a structure for Australian and New Zealand primary health practitioners, gastroenterologists, surgeons, endocrinologists, anaesthetists and perioperative physicians to support clinical decisions in these patients.

This study aimed to characterise specialist palliative care service involvement within the intensive care unit (ICU) and subsequently in post-ICU hospital wards, and compare current ICU referral practices with those suggested by an internationally utilised ICU palliative care referral tool. This was a retrospective cohort study, carried out at a large university-associated ICU in Melbourne, Australia, and was conducted on adult patients aged at least 18 years admitted to ICU between July 2019 and July 2023. The study included 11,449 ICU admission episodes relating to 10,171 patients. The overall ICU mortality for all patients was 9% in ICU with a further 4.3% post-ICU. Within non-survivors, specialist palliative care involvement was uncommon for patients who died in ICU (78/1035, 7.5%), but substantial (287/488, 59%) for those ICU patients who died on a hospital ward after ICU discharge. Compared with ICU patients who did not have an identified palliative care referral, ICU patients with palliative care input averaged longer ICU stays with shorter hospital stays post-ICU discharge. The referral tool showed low sensitivity (39%) when compared with observed current ICU palliative care referral practice. Clinical staff within the ICU provided the majority of palliative care for ICU patients, with a palliative care consultative service taking a proportionally much greater role in post-ICU hospital wards. The selected criteria appeared inadequate for use as an effective referral tool. Future research may explore the quality of palliative care provided by ICU staff and specialist palliative care staff, and the role of decision support tools, so as to provide optimal care for critically ill patients approaching the end of life.

In the second half of the nineteenth century and up to the First World War, anaesthetic practice in Scotland differed markedly from that in England. Chloroform was invariably used in Scotland with apparent disregard for reports of deaths under its influence. By contrast, in England concern about chloroform deaths, which were subject to inquests there, led to ether often being chosen instead. This article examines the different interpretations and handling of chloroform deaths in the two countries, drawing on the medical journals of the period and archived documents. Quite symmetrical claims were made. Whereas in England the danger of chloroform was perceived to be an inherent property of the agent itself, in Scotland the blame was thrown on a timid method of administration. The interpretation in Scotland was supported by a network of doctors who promoted chloroform as effective, safe and easy to administer; manufacturers who had monopoly of its manufacture; and legal practitioners who were uninterested in investigating anaesthetic deaths. Although the reporting of anaesthetic deaths was flawed in England, underreporting was far worse in Scotland. The fear of anaesthetic deaths in England allowed the seeds of specialisation in anaesthesia to germinate, whereas in Scotland the downplaying of anaesthetic risk obviated the notion of such specialisation.

James Young Simpson's Notice of a New Anaesthetic Agent is a rare pamphlet of which three copies have hitherto been documented. Two of the three known copies were inscribed by Simpson with the words 'proof copy'. A fourth copy of the pamphlet, also inscribed with the words 'proof copy', has been identified. Although regarded by Simpson as a proof copy, there is previously unreported evidence that the pamphlet was advertised by the publisher on 12 November 1847, published on 13 November 1847, and sold on that day by booksellers in Edinburgh. Thus, the Notice pamphlet was the first published report of the use of chloroform as an anaesthetic agent. The pamphlet was issued 2 or 3 days before the well-known revised edition bearing the title Account of a New Anaesthetic Agent, and one week before the publication of Simpson's papers on chloroform in The Lancet and the Medical Times.

The study objective was to determine the incidence of complications from induced hypertension used to treat delayed cerebral ischaemia (DCI) complicating aneurysmal subarachnoid haemorrhage (aSAH). Induced hypertension (IH) was defined as the use of vasopressors to achieve a supraphysiological systolic blood pressure target. A single-centre retrospective, observational cohort study was undertaken at the Royal Adelaide Hospital intensive care unit. Data are presented as predominantly median (interquartile range (IQR)). All patients admitted with a diagnosis of aSAH between 1 April 2020 and 1 April 2022 were included and analysed according to whether they did or did not receive vasopressors for IH. A total of 109 patients were included, of which 29 (27%) received vasopressors for IH (median age 58 (IQR 52-65) years, 65% female) and 80 did not receive IH (median age 55 (IQR 49-71) years, 62% female). Clinical DCI or radiological evidence of vasospasm were present in all patients given IH and in 16% of non-IH patients. Patients in the IH group had more ischaemic electrocardiogram (ECG) changes (17.2% vs 2.5%, P = 0.01), urine output (4807 (IQR 3186-5720) ml/day vs 2125 (IQR 1650-2760) ml/day, P < 0.001), fluid administration (4895 (IQR 3555-5999) ml/day vs 2704 (IQR 2300-3403) ml/day, P < 0.001) and intravenous potassium replacement (13 (IQR 5-24) mmol/day vs 5 (IQR 0-13) mmol/day, P = 0.001) than those in the non-IH group. IH was also associated with a greater incidence of hyponatraemia (58% vs 34%, P = 0.02). IH was not associated with arrhythmias or rebleeding. Mortality rates were 17% vs 20% (P > 0.9) in the IH and non-IH groups respectively. In conclusion, IH for the treatment of DCI following aSAH was associated with an increased rate of ischaemic ECG changes, increased urine output and hyponatraemia. However, in the IH group there was no increased rate of rebleeding, and 48% of the IH patients had an improvement in their neurological function following commencement of treatment.