{"title":"Ethical issues in resuscitation and intensive care","authors":"Jill Keohone, Paul McConnell","doi":"10.1016/j.mpaic.2024.08.006","DOIUrl":"10.1016/j.mpaic.2024.08.006","url":null,"abstract":"<div><div>Advances in the care of critically unwell patients have begun to blur the boundaries between life and death; coupled with an ageing population, intensive care physicians routinely make difficult decisions in their clinical work. The model of supported decision-making with patients has become standard, however, patients in the intensive care unit (ICU) are often unable to express their wishes at the point of admission. Recent legal cases have resulted in increased scrutiny upon the decisions we make when caring for patients unable to consent to treatment, due to incapacity and critical illness, particularly when they involve the limitation or discontinuation of life supporting therapies. A robust understanding and application of the moral, ethical and legal frameworks are useful to aid in making decisions in patients’ best interests when faced with clinical dilemmas on the ICU.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 788-791"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Premedication","authors":"Ruth McGovern, Leo G Kevin","doi":"10.1016/j.mpaic.2024.08.005","DOIUrl":"10.1016/j.mpaic.2024.08.005","url":null,"abstract":"<div><div>Administration of medications in advance of induction of anaesthesia, ‘premedication’, has a long history. With the earliest inhalational agents, ether and chloroform, induction was characterized by a prolonged period of involuntary movements, excessive salivation and feelings of severe anxiety. It became common practice, therefore, to premedicate patients with agents such as scopalamine (an early anticholinergic) to reduce secretions, and morphine, to reduce irritability and anaesthetic requirements. In the 1950s came intravenous induction agents and halogenated inhalation agents, and a smoother and more predictable induction and early maintenance phase, with much reduced salivation. The practice of premedication lingered however, although its main purpose was now simply to alleviate patient anxiety. The invention of benzodiazepines in the late 1950s was nicely timed to find for them a niche as favoured anxiolytic premedication. This persisted for many years. In modern anaesthesia practice, sedative/anxiolytic premedication is much less commonly used than heretofore. The pre-assessment consultation with the anaesthetist has largely replaced routine premedication for the purpose of alleviating anxiety, as several studies show that this can be quite effective in achieving a calm patient. The term premedication has lately taken on a broader meaning. It is now understood to include considerations regarding which of the patient's long-term medications should be withheld or continued in advance of their operation, and the introduction of medications with the aim of optimizing medical conditions or to improve certain peri-operative outcomes.</div><div>In this article we will first discuss premedication for the purposes of sedation/anxiolysis. We will then systematically examine some of the medications that are commonly the focus of preoperative decisions in the surgical patient. The list of medications discussed is by no means exhaustive. Finally, we will look at premedication in special patient populations.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 749-752"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Drugs affecting coagulation","authors":"James Barrowman, Ming Wilson","doi":"10.1016/j.mpaic.2024.06.008","DOIUrl":"10.1016/j.mpaic.2024.06.008","url":null,"abstract":"<div><div>The clotting cascade is a complex process and is an important survival mechanism. Major haemorrhage and thromboembolic events remain major causes of increased morbidity and mortality. Drugs affecting coagulation have primarily been utilized to treat or reduce the risk of thromboembolic events. However, the recent progress in the management of major trauma and treating coagulopathy has resulted in further research and development of drugs that improve clotting function. Knowledge of drugs used for both clinical circumstances is now required when working in anaesthesia or intensive care.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 714-722"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419317","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Acute and chronic airway obstruction in children","authors":"Graham Bell, William Shankey-Smith","doi":"10.1016/j.mpaic.2024.07.008","DOIUrl":"10.1016/j.mpaic.2024.07.008","url":null,"abstract":"<div><div>Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 677-684"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Developmental anatomy of the airway","authors":"Thokozani M Zhande, Alasdair Howie","doi":"10.1016/j.mpaic.2024.07.005","DOIUrl":"10.1016/j.mpaic.2024.07.005","url":null,"abstract":"<div><div>A thorough understanding of the airway anatomy, as well as the differences that exist between the paediatric and the adult airway is crucial for one to safely manage it. The human airway originates from the primitive foregut at 4 weeks' gestation and fully matures at 36 weeks’ gestation. At birth, the term neonate has a relatively large head, flat occiput, short neck, small mouth opening and a small mandible; features which make them prone to upper airway obstruction as well as a difficult laryngoscopy. Neonates are obligate nasal breathers; allowing them to breathe and suckle simultaneously. The Hagen–Poiseuille equation explains how nasal congestion causes obstruction in neonates which can lead to the development of significant respiratory distress.</div><div>The subglottic area of the airway is the most susceptible area to damage from intubation or instrumentation of the airway resulting in subglottic stenosis. Correct endotracheal tube sizing and meticulous attention to detail with respect to cuff pressure are essential to prevent damage to the airway.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 671-676"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Nosocomial infections in the intensive care unit","authors":"Frances Lanaghan, Peter Stenhouse","doi":"10.1016/j.mpaic.2024.07.003","DOIUrl":"10.1016/j.mpaic.2024.07.003","url":null,"abstract":"<div><div>Nosocomial infections are associated with a significant morbidity, mortality, resource and financial burden in ICU. Critical care patients are at an increased risk of developing infections compared to patients elsewhere in hospital due to underlying comorbidities of the patient, the acute disease process and treatments required. There is a strong association with indwelling devices in the ICU population. As such, daily review of ongoing requirement for the invasive device and the application of care bundles, as well as the introduction of local policies targeting hand hygiene and infection control protocols to manage infections have been promoted. Ventilator-acquired pneumonia and catheter-related infections are most common. Management of these frequently involves empirical antimicrobials, although targeted therapy based on culture sensitivities and input from the local microbiology team and infection control team are suggested. There is an increasing burden of antimicrobial resistance in part due to the clinical condition of ICU patients and the frequent use of empirical broad-spectrum antibiotics.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 652-656"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419796","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Assessment and management of the predicted difficult airway in neonates, infants and children","authors":"Johnny Kenth, Robert Walker","doi":"10.1016/j.mpaic.2024.07.006","DOIUrl":"10.1016/j.mpaic.2024.07.006","url":null,"abstract":"<div><div>Few scenarios in medicine incite as much apprehension as encountering a child with an anticipated or unanticipated difficult airway. Navigating the paediatric airway landscape necessitates not only precision but also a highly adaptable approach due to the unique anatomical and physiological challenges presented by neonates, infants, and children. This review highlights the critical importance of comprehensive preoperative evaluation, integrating detailed patient history, meticulous physical examinations, and previous medical records to predict potential airway difficulties accurately. Central to the management strategy is the development of a robust, adaptable plan that incorporates the use of both basic airway devices and advanced technological aids such as video-laryngoscopes and flexible bronchoscopes. These tools aim to enhance success rates while minimizing patient trauma. Axiomatic to this discussion is the formulation of strategies that effectively mitigate hypoxia and ensure successful airway control with minimal attempts. The review also addresses special considerations, such as the strategic management of difficult extubation and the application of algorithmic approaches to airway management, equipping practitioners to handle both anticipated and unanticipated challenges proficiently. By amalgamating and contextualizing insights from clinical practice and evidence-based recommendations, this review aims to arm healthcare providers with the knowledge and skills essential for optimizing paediatric airway management outcomes, thereby enhancing safety and efficacy in paediatric anaesthesia and critical care.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 685-702"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jeffrey Wayland, J. Pedro Teixeira, Nathan D. Nielsen
{"title":"Sepsis in 2024: a review","authors":"Jeffrey Wayland, J. Pedro Teixeira, Nathan D. Nielsen","doi":"10.1016/j.mpaic.2024.06.010","DOIUrl":"10.1016/j.mpaic.2024.06.010","url":null,"abstract":"<div><div>Sepsis is responsible for tremendous morbidity, mortality, and healthcare expenditure worldwide. Over the past decade, the conceptualization of sepsis has shifted from one based upon an inflammatory response to one defined by a dysregulated immune response to infection and resulting organ dysfunction. The definitions of sepsis and septic shock were revised to improve their diagnostic specificity and facilitate accurate and timely diagnoses at the bedside. The core of sepsis management remains <em>early</em> identification and diagnostic testing, <em>early</em> antimicrobial therapy, and <em>early</em> haemodynamic resuscitation. Recently, there has been additional movement towards classifying and treating sepsis based on genotype, phenotype, and endotype, though these methods are not yet widely accessible or adopted. Current guidelines recommend that the first steps in treatment and resuscitation take place within <em>1 hour</em> from when septic shock is suspected. Additional essential elements in the current sepsis management guidelines include using dynamic parameters to assess fluid responsiveness, a conservative fluid strategy following initial resuscitation (with subsequent de-resuscitation when possible), serial reassessments of haemodynamic status, and adaptable treatment plans. This review provides a summary of the most recent clinical trials and practice guidelines for the diagnosis and treatment of sepsis in the critical care setting.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 642-651"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Physical rehabilitation and critical illness","authors":"Katherine Cox, Alana Rix, Carol L. Hodgson","doi":"10.1016/j.mpaic.2024.06.012","DOIUrl":"10.1016/j.mpaic.2024.06.012","url":null,"abstract":"<div><div>With the evolution of interventions in the intensive care unit (ICU), an increasing number of patients are surviving critical illness. Survivors of critical illness commonly experience post-intensive care syndrome (PICS), which encompasses a range of physical, cognitive, social, and psychological impairments that persist well beyond discharge from hospital. Physical rehabilitation is an intervention that is implemented to prevent and treat the physical impairments that manifest as part of PICS. There is significant evidence to support functional, goal-directed physical rehabilitation interventions in ICU as it is shown to improve physical function without increasing the risk of adverse events. There are clear guidelines that outline the specific safety criteria for commencing physical rehabilitation in ICU, however, there is further research warranted to determine the optimal dosage. Beyond the ICU admission, there are limited recommendations regarding ongoing physical rehabilitation however there is emerging evidence to support the implementation of home-based telehealth programmes to help improve patient's strength, endurance, and quality of life. Regardless, it is recommended that physical rehabilitation is delivered as part of routine care during an ICU admission and continue throughout the transitions of care to enable the best possible recovery.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 664-670"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419798","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Self-assessment","authors":"Vijayanand Nadella","doi":"10.1016/j.mpaic.2024.08.014","DOIUrl":"10.1016/j.mpaic.2024.08.014","url":null,"abstract":"","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 741-742"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419795","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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