{"title":"Risk modification and preoperative optimization of vascular patients","authors":"Ben A Goodman, Adam Pichel, Gerard R Danjoux","doi":"10.1016/j.mpaic.2024.11.011","DOIUrl":"10.1016/j.mpaic.2024.11.011","url":null,"abstract":"<div><div>Major vascular surgery is associated with a high risk of morbidity and mortality. Targeted optimization of organ systems most likely to suffer morbidity should be made prior to elective surgery. Risk modification can reduce both perioperative and long-term complications. This article summarizes currently accepted best practice for risk modification and preoperative optimization prior to vascular surgery.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 71-74"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163355","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":"Anaesthesia for ruptured aortic aneurysm","authors":"Jonathan Brown, Shilpa Munirama","doi":"10.1016/j.mpaic.2024.11.008","DOIUrl":"10.1016/j.mpaic.2024.11.008","url":null,"abstract":"<div><div>The incidence of ruptured abdominal aortic aneurysm (rAAA) has been reduced by a national screening programme targeting early identification and treatment of aneurysms. Despite these efforts, rAAA remains a common anaesthetic and surgical emergency responsible for over 5000 deaths per year in the UK. rAAA leads to complex multiorgan critical illness which requires immediate multidisciplinary collaboration and intervention. Anaesthetists play a key role in resuscitation, coordination of care and managing major haemorrhage and multi-organ sequelae of a ruptured aorta. In this article, we describe an overview of the risk factors, current guidelines, service organization, and treatment for rAAA; with focus on the perioperative anaesthetic considerations for open aneurysm repair and endovascular aneurysm repair.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 102-107"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163359","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":"Applied cardiovascular physiology","authors":"Carla Gould, Jon Hopper","doi":"10.1016/j.mpaic.2024.11.005","DOIUrl":"10.1016/j.mpaic.2024.11.005","url":null,"abstract":"<div><div>Maintaining an equilibrium between oxygen supply and demand is a principal function of the cardiovascular system. In times of altered metabolic demand, mechanisms exist to maintain the balance between supply and demand. Exercise, haemorrhage and pregnancy all lead to changes in oxygen demand and subsequently modification of cardiac output. During isotonic exercise, metabolic demands of muscle are greatly increased. Sympathetic stimulation and inhibition of the parasympathetic system lead to increases in heart rate and venous return, increasing cardiac output. This allows a proportional increase in blood flow to the exercising muscle. Cardiac output increases throughout pregnancy. In the first and second trimesters this rise is mainly due to an increase in stroke volume; however, during the later stages of pregnancy stroke volume reaches a plateau and further increase in cardiac output is mediated by a rising heart rate. In contrast, during haemorrhage, decreased venous return leads to a reduction in cardiac output, with a baroreceptor response due to the drop in arterial blood pressure. The tachycardia and vasoconstriction which follows are compensatory mechanisms in an attempt to preserve blood pressure. The Valsalva manoeuvre illustrates several aspects of reflex control of the cardiovascular system and allows non-invasive assessment and quantification of control mechanisms. Changes in stroke volume during the respiratory cycle can be used to predict fluid responsiveness and can be measured as pulse pressure variation or stroke volume variation.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 118-121"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163296","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.2024.12.007","DOIUrl":"10.1016/j.mpaic.2024.12.007","url":null,"abstract":"","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 127-128"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163297","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":"Neurological and humoral control of blood pressure","authors":"Jaideep J. Pandit","doi":"10.1016/j.mpaic.2024.11.003","DOIUrl":"10.1016/j.mpaic.2024.11.003","url":null,"abstract":"<div><div>There is a relationship between arterial blood pressure, cardiac output and vascular resistance described mathematically, that helps us to understand short-term control of blood pressure in terms of a hydraulic system. Arterial baroreceptors are specialized sensors mediating a rapid response to changes in pressure through interaction with the autonomic nervous system. This in turn influences heart rate, inotropic state and vascular tone, altering distribution of blood between arterial and venous systems, compensating for acute changes in total blood volume. Total blood volume is controlled predominantly by the kidney, with the renin–angiotensin–aldosterone system acting as both the ‘sensor’ of blood pressure/volume (via the juxtaglomerular apparatus) and the ‘effector’ of blood pressure/volume (via renin and aldosterone secretion). Overall control is shared; the baroreceptors being responsible for mediating short-term changes, and renal mechanisms determining the long-term control of blood pressure. These systems have to be adaptable in order to deal with physiological variation in the delivery of blood to tissues from rest to exercise, and with the large shifts in blood volume seen in acute haemorrhage. Pathophysiological changes in these systems lead to maladaptive responses, with systemic hypertension the most commonly seen.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 122-126"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143164504","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":"Pre-optimization of the anaemic patient","authors":"Sarah-Lindsay Holmes, Harriet Lucero","doi":"10.1016/j.mpaic.2024.09.012","DOIUrl":"10.1016/j.mpaic.2024.09.012","url":null,"abstract":"<div><div>Anaemia affects a significant number of preoperative patients and has independently been associated with increased morbidity and mortality. Identification, assessment, and treatment of preoperative anaemia is now widely accepted as a new standard of care for patients. There remains a lack of conclusive evidence that optimizing the haemoglobin (Hb) preoperatively impacts on the increased risks, but there is increasing evidence normalizing iron stores has a positive impact.</div><div>The commonest cause of anaemia in this setting is iron deficiency. It is important to consider and exclude other causes, there are established recommendations for screening investigations. Early identification allows time for Hb optimization. Oral iron replacement is advised first line, however there are often time constraints and tolerability concerns. In some circumstances surgical delay is appropriate. It is important patients understand the rationale behind management and are involved in the decision-making process. Where possible, red cell transfusions are avoided preoperatively given associations with worse surgical outcomes, there may be circumstances however where both transfusions and erythropoiesis stimulating agents are considered.</div><div>As evidence and research in this field grows hospitals should develop preoperative anaemia care pathways to ensure appropriate screening investigations are performed and management delivered.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 1","pages":"Pages 1-5"},"PeriodicalIF":0.2,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143143469","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":"Iron metabolism","authors":"Emma MacGregor, Deirdre Conway, Mark A Henderson","doi":"10.1016/j.mpaic.2024.11.001","DOIUrl":"10.1016/j.mpaic.2024.11.001","url":null,"abstract":"<div><div>Iron – like most micronutrients – is not synthesized by the human body and is acquired from dietary sources. Total body iron (approximately 3000–5000 mg) is chiefly regulated by varying the rate of absorption, balancing daily loss. Iron undergoes a continual cycle of conservation and re-utilization, with precise physiological controls to avoid systemic toxicity from free iron. Iron exerts pivotal roles in oxygen transport by haemoglobin, adenosine triphosphate generation, and enzymatic function. Iron deficiency anaemia is often identified in the preoperative period. Furthermore, syndromes of iron overload and subsequent toxicity may arise from aberrant pathways of iron metabolism.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 1","pages":"Pages 53-56"},"PeriodicalIF":0.2,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143144013","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":"Capillary dynamics, interstitial fluid and the lymphatic system","authors":"Andrew Haggerty, Mahesh Nirmalan","doi":"10.1016/j.mpaic.2024.10.004","DOIUrl":"10.1016/j.mpaic.2024.10.004","url":null,"abstract":"<div><div>The regulation of small blood vessels (arterioles, venules and capillaries) and the formation of interstitial fluid at the capillary beds is an important process in the understanding of the healthy circulation. Traditionally, Starling's forces have been at the very heart of our understanding of this system. However, more recent work shows that the transvascular fluid flux is significantly lower than what one would expect on the basis of Starling’s forces alone, and hence alternative explanations have been sought to understand the process of tissue fluid formation. In this context the role of the endothelial glycocalyx layer (or EGL) has drawn substantial interest. The EGL is a dynamic, active interface between the blood and the endothelial cells. It is formed by membrane-bound glycoproteins, proteoglycans and polysaccharides, producing a hydrated gel-like layer on the luminal surface of the vascular endothelium of approximately 500–2000 nm thickness. In this paper we review some of these emerging concepts and propose alternative ideas to understand some frequent clinical conditions and their treatment.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 1","pages":"Pages 61-68"},"PeriodicalIF":0.2,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143144010","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":"Clinical aspects of coagulation and haemorrhage","authors":"Muhammad Naim Che Rahimi, Nicola Curry","doi":"10.1016/j.mpaic.2024.09.011","DOIUrl":"10.1016/j.mpaic.2024.09.011","url":null,"abstract":"<div><div>Haemorrhage affects all patient groups. Coagulopathy (an abnormality of the clotting system) is closely interlinked with haemorrhage and can either place patients at risk of future bleeding or can exacerbate active ongoing bleeding. There are many causes of coagulopathy – both inherited and acquired. During major haemorrhage, the presence of an acquired coagulopathy increases the likelihood of a poor clinical outcome, and a patient is more likely to require large transfusion volumes, critical care admission and is three to four times more likely to die. Other forms of coagulopathy, such as drug-induced coagulopathy (anticoagulant/anti-platelet use), liver disease or inherited bleeding disorders, both increase the severity of any active bleeding and place patients at higher risk for future bleeding when exposed to a haemostatic challenge, such as surgery. This risk must be recognized and mitigated. This review focuses on the clinical aspects of coagulation and haemorrhage in all these patient groups.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 1","pages":"Pages 20-26"},"PeriodicalIF":0.2,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143144001","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":"Ethics of pregnancy testing in patients undergoing anaesthesia and surgery","authors":"Rachel Fairlie, Paul McConnell","doi":"10.1016/j.mpaic.2024.10.002","DOIUrl":"10.1016/j.mpaic.2024.10.002","url":null,"abstract":"<div><div>A patient's pregnancy status should be determined prior to undergoing any procedure which has the potential to cause harm to a pregnant mother or fetus. Anaesthesia and surgery, alongside the associated physiological stress and radiation exposure, pose some increased risks to the pregnancy and developing fetus. The fetus is most vulnerable in the first trimester, when the mother is more likely to be unaware of the pregnancy. National guidance suggests all women of child-bearing potential should be offered a pregnancy test prior to surgery if pregnancy status is uncertain. The results of this test can be used to inform decision-making regarding anaesthetic and surgical techniques, and in relation to timing of surgery. Whilst the testing is done in part to protect the unborn child, the fetus in of itself has no legal personality or rights until birth, and ultimately the decision to consent to surgery is that of the patient. Elective procedures can be postponed to minimize the risk to the pregnancy of miscarriage or teratogenicity. Most patients will be able to consent to pregnancy testing and the procedure. Potential ethical issues arise if the patient lacks capacity or is under the age of 16.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 1","pages":"Pages 27-30"},"PeriodicalIF":0.2,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143144011","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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