Current anaesthesia and critical care最新文献

Glaucomatous eyes are at heightened risk of optic nerve damage from local anaesthesia, and this may cause ‘wipe-out’ of vision. Most glaucoma surgery is done on the anterior part of the globe, and can be performed using any of the standard anaesthesia techniques. However, many surgeons prefer to avoid putting any LA near to the optic nerve, and simply anaesthetise the surgical area. Options include sub-conjunctival, sub-Tenon’s, or topical anaesthesia.

Glaucoma patients may, of course, have surgery for other reasons. The anaesthesiologist needs to be familiar with the systemic side-effects and interactions of glaucoma medications.

Acute rise in intra-ocular pressure may occur in predisposed eyes, and this can be sight-threatening. Acute angle closure glaucoma is discussed, along with a 3-step method to identify patients at risk. Patients who have recently had an intra-ocular gas bubble (with vitrectomy surgery) are at risk of blindness if they have a general anaesthesia with nitrous oxide, in the weeks before the bubble has dissolved.

Excessive tearing due to obstruction of the nasolacrimal duct is a common ophthalmic problem. Dacryocystorhinostomy (DCR) is the procedure designed to treat primary or secondary adult anatomical obstruction. External DCR is the traditional surgical approach, however endoscopic DCR can be done. In the past, general anaesthesia (GA) has been considered as the gold standard for DCR surgery; endotracheal intubation and throat pack offer an important function as protective mechanisms of the patient’s airway against blood aspiration. Head up position, hypotensive anaesthesia, incision infiltration with lidocaine/epinephrine together with insertion of nasal pack soaked in decongestant solution are a routine measures to guard against intraoperative bleeding that may hinder surgical site visualization. Increase awareness of regional anaesthesia efficacy contemplated the surgeons towards the use of such techniques. The basic concept of local anaesthesia for DCR involves blockade of infratrochlear, infraorbital and anterior ethmoidal nerves either by separate injections or by local infiltration along with intranasal preparation. It has been found that DCR under regional anaesthesia minimizes intraoperative bleeding, inpatient stay and reduce health care expenditure. Further, many patients prefer regional anaesthesia due to less postoperative pain. These benefits are desirable particularly in elderly population in whom GA constitute a threat for their life.

An anaesthetic presence is often questioned in operations that can be performed under topical anaesthesia. However, the anaesthetist role extends far beyond providing general anaesthesia. They can provide sedation if required, have the ability to perform different regional blocks, and to treat both acute and chronic orbital pain conditions. Of as great importance is that anaesthetists routinely monitor patients under a wide range of anaesthetics and are able to identify and manage serious life threatening complications if they happen perioperatively.

Subjective visual perceptions during intraocular ophthalmic surgery under regional anaesthesia are now well recognised. They range from simple light perception to seeing vivid colours, intricate movements, flashes and instruments. Surgeons, anaesthetists and patients should be aware of these phenomena. Although the majority of the patients find visual perceptions bearable some may be frightened. Preoperative counselling should therefore be offered to patients. This article reviews the range and clinical implications of subjective visual perceptions during intraocular surgery and explores the mechanisms behind their genesis.

Enhanced Recovery Programmes have been demonstrated to improve short-term outcomes after major abdominal surgery, and are considered best practice.

The aim of this work is to share the experience and outline the process of the design; development; & implementation of an Enhanced Surgical Treatment & Recovery Programme (ESTReP), and also to provide recommendations for ongoing programme maintenance and improvement.

Targeted Fluid Adminstration (TFA) is a technique using less invasive cardiac output monitors to guide individualised intra-operative fluid therapy. Typically, the anaesthetist administers boluses of approximately 200–250 ml of colloid solution whilst measuring changes in stroke volume or another measure of fluid responsiveness, such as stroke volume variation. When the stroke volume measurements indicate that the cardiovascular system is no longer fluid responsive, the patient is assumed to be close to the upper flat phase of the Frank–Starling Curve. Research using TFA suggests that post-operative complications such as ileus and length of hospital stay are reduced when fluid therapy is managed in this way. Most of the positive evidence for TFA has been achieved using the oesophageal Doppler (CardioQ, Deltex Medical, Chichester UK), although other cardiac output monitors are available, there are few clinical outcome studies that justify their use in routine practice. Widespread adoption of TFA for patients undergoing major surgery will help achieve the goals of enhanced recovery.

Pre-operative preparation is the first stage in the enhanced recovery process. If it goes wrong it will adversely impact on the peri and post-operative stages of enhanced recovery. If done well it enables the success of enhanced recovery. At this stage the expectations of the patient and their family are set to prepare them for the planned surgery and its effects on the patient. It involves both primary and secondary care. Information is transferred both from the patient and to the patient. This is done by verbal, written and increasingly electronic communication. The patient is evaluated to ensure that there is no medical or social cause to prevent the enhanced recovery process. This has been referred to in the past as pre-assessment but is probably more accurately called pre-operative preparation.