#34837对不良合并症和智力下降的患者进行局部麻醉的决策框架

Tong-Khee Tan
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摘要

请确认已申请或授予伦理委员会批准:不相关(见本页底部信息)ESRA摘要奖申请:我不希望申请ESRA奖背景和目的知情同意书是区域麻醉的基石。在缺乏精神能力的患者中,执行特定区域技术/替代方案的风险将无法传达。使用局部麻醉的决定可能会让麻醉师感到不舒服,尤其是当不称职的病人没有家庭成员/法律代表时。这张海报建议使用Jonsens的4box方法(1)来帮助麻醉师在对非最佳患者使用局部技术时做出决策/证明。方法85岁重度痴呆患者x先生,卧床不起,来自国营特困老人之家。他因右前足湿性坏疽入院,病情严重。他发展为败血症相关的心肌梗死,需要双重抗血小板药物(氯吡格雷,阿司匹林)。尽管患者处于凝血障碍状态,但仍计划在腘/隐神经阻滞下进行清创/脚趾截肢。方框1:医学指征。消除脓毒症源头,减轻疼痛,无全身麻醉风险。Box2:病人的偏好。当凝血功能障碍并伴有血肿/神经损伤等并发症时,他是否需要局部阻滞手术?由于能力不足,需要紧急手术,麻醉师根据最佳利益/必要性做出决定。专栏3:生活质量。他的病前状态很悲惨,但他目前的状态更糟,因为他在疼痛和化脓。Box4:上下文特征。有一只臭/痛的化脓性坏疽脚是没有尊严的。鉴于患者近期梗死,局部麻醉较全麻安全。并非没有风险,块的外围性质和使用超声波引导使其更安全。结论四盒方法可用于指导凝血障碍患者在无法讨论风险和替代方案的情况下进行神经阻滞的决定。首要考虑的是他的尊严和舒适。附件AbstractJonsen AR.docx
本文章由计算机程序翻译,如有差异,请以英文原文为准。
#34837 Decision-making framework to undertake regional anaethesia in patients with poor comorbidities and diminished mental capacity

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes: I don’t wish to apply for the ESRA Prizes

Background and Aims

Informed consent forms the cornerstone of regional anaesthesia. In patients lacking mental capacity, risks of a performing a particular regional technique/alternatives would not be able to be conveyed. The decision to use regional techniques may make anaesthetists uncomfortable especially if the incompetent patient has no family members/legal representatives. This poster suggests using Jonsens’s 4box approach(1) to aid anaesthetists’decision-making/justification when using regional techniques in sub-optimal patients.

Methods

85 year old severely demented Mr.X, bedbound, was from state-run nursing home for destitutes. He was admitted with wet gangrene of right forefoot,in severe distress. He developed a sepsis-related myocardial infarction needing dual anti-platelets(clopidogrel,aspirin). A debridement/toes amputation was planned,under popliteal/saphenous nerve block,despite his coagulopathic state.

Results

Box1:Medical indications. To remove source of sepsis and pain relief, without general anaesthetic risks. Box2:Patient preference. Would he want surgery under regional block when coagulopathic, with complications such as haematoma/nerve injury? Lacking capacity and needing urgent procedure, the anaesthetist made decisions based on best interest/neccesity. Box3:Quality of life. His premorbid state was miserable but his current state worse as he was in pain and septic. Box4:Contextual features. There was no dignity having a smelly/painful septic gangrenous foot. Regional technique was safer than general anaesthetic in view of his recent infarction. Not without risks, the peripheral nature of the block and using ultrasound guidance made it safer.

Conclusions

The four box approach was used to guide decision to perform a nerve block in a coagulopathic patient, who was unable to discuss risks and alternatives. The over-riding consideration acutely was his dignity, comfort.

Attachment

AbstractJonsen AR.docx
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