Anaesthesia and Intensive Care最新文献

Limited data suggest a subset of patients with acute respiratory distress syndrome receive high-dose and prolonged opioid and sedative infusions. With prolonged use, patients may be at risk for developing iatrogenic withdrawal syndrome after discontinuation or tapering of these agents. Iatrogenic withdrawal syndrome is well described in paediatric patients; however, limited guidance exists in adult intensive care unit patients regarding risk factors and ideal management strategies. This article discusses several weaning strategies for high-risk patients to minimise withdrawal symptoms and safely reduce or discontinue opioid and sedative infusions. Ideal weaning strategies are lacking, but several options exist. These include a gradual reduction of the agent, changing the route of delivery by switching to an enteral or parenteral longer-acting agent from the same class, and substitution to an alternative agent to help mitigate potential withdrawal symptoms. This should be accomplished through a multidisciplinary approach by involving experts from relevant specialties while closely observing for withdrawal symptoms.

The increasing prescription of glucagon-like peptide 1 (GLP-1) agonists presents a peri-operative challenge for anaesthetists. These drugs delay gastric emptying, potentially increasing pulmonary aspiration risk. Despite recent recommendations from the Australian and New Zealand College of Anaesthetists, Australian Society of Anaesthetists, and American Society of Anesthesiologists, there remain no formalised guidelines regarding preoperative optimisation for patients taking GLP-1 agonists. Given the current lack of evidence, we present a case series of incidents involving patients treated with GLP-1 agonists reported to webAIRS, a web-based anaesthetic incident reporting system in Australia and New Zealand. Among 11,700 reports from July 2009 to April 2024, 13 incidents related to GLP-1 agonist use were identified, including seven cases concerning aspiration. Patient factors potentially contributing to increased aspiration risks in these incidents included a higher body mass index, type 2 diabetes mellitus, gastro-oesophageal reflux disease, emergency case, and time from GLP-1 agonist cessation. Most incidents involved a rapid sequence induction for general anaesthesia with no cases utilising gastric ultrasound, preoperative nasogastric tube insertion, or intravenous erythromycin use. This case series highlights the potential concerns relating to GLP-1 treatment in the perioperative setting. Interdisciplinary collaboration and communication between anaesthetists, surgeons, general practitioners and endocrinologists are required to further investigate and establish preoperative guidelines for safe GLP-1 agonist use. Specifically, consideration in determining actual gastric contents of each patient despite generic fasting guidelines is needed. Early preoperative risk stratification should also improve patient safety and outcomes.

Anaesthetic airway incidents persist as a significant concern in patient safety and, despite extensive investigations, continue to cause patient harm. Traditional safety investigations predominantly adhere to Safety-I principles, focusing on identifying and rectifying errors, often yielding limited new findings. In this analysis conducted within the webAIRS database, the focus shifted towards Safety-II principles. The aim of this study was to identify factors contributing to airway management safety by examining incidents that did not result in adverse patient outcomes. Incidents categorised as 'difficult intubation' or 'failed intubation' without causing harm to the patient and reported to webAIRS between 2016 and 2022, were included in the analysis.An inductive qualitative content analysis of narrative data from 129 such incidents revealed that the majority of reported events depicted scenarios deviating from controlled and planned circumstances. During the analysis four themes were identified: patient factors, system factors, individual anaesthetist factors and airway management strategy. Within the first three themes, multiple factors were linked to airway management strategies. The findings of this qualitative analysis show that 'Work as done' often differs from 'Work as imagined'.This qualitative analysis highlighted the dynamic nature of human management, as individuals respond to unplanned or unexpected events, showcasing adaptability and positive contributions to incident performance. Expanding the understanding of patient safety to also include Safety-II principles, provides a deeper and wider understanding of airway management safety.

Most procedures in cardiac catheterisation laboratories (CCLs) have traditionally been performed under conscious sedation under the supervision of the treating proceduralist. With growing demand for more complex procedures to be performed, in emergencies and in patients with limited cardiorespiratory reserve, a reconsideration of the level of supervision provided is required. We conducted a retrospective cohort study of all patients who had CCL procedures and required an overnight stay at Royal North Shore Hospital during a 12-month period prior to introducing monitored anaesthesia care (MAC), compared with a 12-month period following introduction of MAC on selected weekdays. Primary outcomes were the difference in rates of Code Blue calls (triggering the cardiac arrest team), Clinical Reviews and Rapid Responses (defined as per the NSW Health 'Between the Flags' Deteriorating Patient Safety Net System) in the 24 h post-procedure between patients who did and did not have MAC. The secondary outcome was a difference in mortality (within 24 h of a procedure and in-hospital) between patients who did and did not have MAC. One thousand nine hundred and eight patients were analysed (926 pre-intervention, 982 post-intervention). We found no statistically significant difference in any of the primary or secondary outcomes between the pre-intervention and post-intervention patients overall. However, we found a statistically significant lower rate of Code Blue calls in patients who had MAC (n = 3, 0.6%) compared with no MAC (n = 31, 2.3%). We also found a significantly lower 24-h mortality in patients who had MAC (n = 1, 0.2%) compared with no MAC (n = 22, 1.6%), but no difference in overall in-hospital mortality.

With increasing gender balance in specialist medical training and employment in Australia, there is a corresponding need to consider how parental leave and subsequent return to work is managed in the workplace. An electronic survey exploring the experiences of pregnancy and return to work following parental leave was distributed by the Australian and New Zealand College of Anaesthetists (ANZCA). The return-to-work component of the survey evaluated parental leave and return-to-work patterns, lactation practices and facilities, supports and resources utilised during the return-to-work process. We report on 391 return-to-work episodes from 219 respondents. One hundred and seventy-two (79%) were specialists at the time of survey completion. Six to 11 months was the most frequent duration of parental leave, and this duration was associated with higher satisfaction levels than shorter durations of leave (odds ratio 5.44, 95% confidence interval 3.18-9.31, P < 0.001). Breastfeeding continued in 246 (63%) return-to-work episodes, and absent or inadequate lactation facilities were reported in 239 (88%). In 227 (58%) return-to-work experiences, respondents received no formal support on returning to work. One hundred and thirty-five (62%) respondents did not utilise any existing return-to-work resources, and family and friends were the main source of support for 113 (52%) respondents. Return-to-work processes should be tailored to meet individual needs. Consistent with existing recommendations, satisfactory lactation facilities must be provided. We recommend that the period of one-to-one supervision be flexible and negotiated, to suit the unique return-to-work trajectory of each worker. Existing ANZCA resources could assist departments in supporting anaesthetists who return to work following parental leave.

Diagnosis of perioperative anaphylaxis (POA) and identification of causative agents remain challenging. This study aimed to describe the estimated incidence, characteristics and causative agents of POA in Malaysia. This is a retrospective review of all cases of suspected POA referred to the only anaesthetic allergy centre in Malaysia from March 2014 to December 2022. One hundred and ninety patients with suspected POA of Grade 2 and above were included. Data on clinical presentation, severity, management, serum tryptase and subsequent allergy workup (including skin and serum testing results) of these patients were extracted from the database. Dynamic tryptase was elevated in half of the cases where tryptase results were available and skin tests were positive in 96% of these cases. Skin testing was positive in 113 patients (60%) overall, and more than 70% of Grades 3 and 4 anaphylaxis cases. Neuromuscular blocking agents (NMBAs) and antibiotics were the most commonly identified causative agents (27.4% and 23% respectively). The commonest NMBAs were rocuronium and atracurium, both commonly cross-reacting with cisatracurium. The overall cross-reactivity rate among NMBAs was 58%. For antibiotics, the commonest causative agents were cefuroxime, ceftriaxone and amoxicillin/clavulanic acid. Using these data, the estimated incidence of Grades 2-4 POA over this period in Malaysia was approximately 1 in 30,000 anaesthetics. However, owing to the voluntary nature of reporting, it is possible that this is an underestimate, particularly in relation to some milder Grade 2 cases which may have gone unrecognised or unreported.