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Postoperative critical care is a finite resource that is recommended for high-risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk-stratified in practice; elucidate clinicians’ opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri-operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real-world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk-averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure-specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri-operative critical care services, such as an overall lack of capacity, competition for beds with non-surgical cases and poor flow through the hospital leading to bed ‘blockages’. Critical care is perceived to provide benefit to high-risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating ‘enhanced care’ units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals. 相似文献
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Marius Rehn Michelle S. Chew Klaus T. Olkkola Kristinn Örn Sverrison Arvi Yli-Hankala Morten Hylander Møller 《Acta anaesthesiologica Scandinavica》2019,63(2):161-163
Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement. 相似文献
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E. Kursumovic T. M. Cook C. Vindrola-Padros A. D. Kane R. A. Armstrong O. Waite J. Soar 《Anaesthesia》2021,76(9):1167-1175
Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics. 相似文献
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D. Sidebotham 《Anaesthesia》2020,75(10):1386-1393
False findings are an inevitable consequence of statistical testing. In this article, I use Bayes’ theorem to estimate the false positive and false negative risks for randomised controlled trials related to our speciality. For small trials in peri-operative medicine, the false positive risk appears to be at least 50%. For trials reporting weakly significant p values, the risk is even higher. By contrast, large, multicentre trials in critical care appear to have a high false negative risk. These findings suggest much of the evidence that underpins our clinical practice is likely to be wrong. 相似文献
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Colin F. Mackenzie MBChB FRCA FCCM Professor Vice-Chairman Director Fred H. Geisler MD PhD Director 《Best Practice & Research: Clinical Anaesthesiology》1999,13(4):643-658
Field assessment, neck immobilization, oxygenation and maintenance of the airway occur in suspected cervical-spine-injured patients before transport to a regional spinal cord injury centre. After cervical spine radiography, bony alignment of the spinal column is re-established and mean blood pressure is maintained at 80–90mmHg with fluids and, if necessary, inotropic support. Predetermined guidelines are used for intubation and ventilation and for invasive monitoring of patients in spinal shock. Fluid challenge is used to assess reserve cardiac function and the need for fluid infusion, restriction or inotropic support. Evoked potential monitoring provides a non-invasive, objective and sensitive method to assess neuroconduction through a spinal cord injury and may be used to replace a wake-up test intraoperatively. There are no randomized prospective studies showing that surgical decompression and/or internal stabilization improves outcome compared with non-surgical treatment of acute cervical spine injury. Respiratory failure is managed by long-term ventilator support, diaphragm pacing or use of glossopharyngeal breathing. Chest physiotherapy is helpful in reducing the occurrence of atelectasis and pneumonia. Hyperreflexic syndromes during surgery are avoided with adequate anaesthesia during stimulation. An area with a population near one million should designate a regional spinal cord injury centre. Such centres decrease the proportion of patients with complete neurological injury. 相似文献
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G. Miao R. P. Ostrowski J. Mace J. Hough A. Hopper R. Peverini R. Chinnock J. Zhang E. Hathout 《American journal of transplantation》2006,6(11):2636-2643
More than half of transplanted beta-cells undergo apoptotic cell death triggered by nonimmunological factors within a few days after transplantation. To investigate the dynamic hypoxic responses in early transplanted islets, syngeneic islets were transplanted under the kidney capsule of balb/c mice. Hypoxia-inducible factor-1alpha (HIF-1alpha) was strongly expressed at post-transplant day (POD) 1, increased on POD 3, and gradually diminished on POD 14. Insulin secretion decreased on POD 3 in association with a significant increase of HIF-1alpha-related beta-cell death, which can be suppressed by short-term hyperbaric oxygen therapy. On POD 7, apoptosis was not further activated by continually produced HIF-1alpha. In contrast, improvement of nerve growth factor and duodenal homeobox factor-1 (PDx-1) production resulted in islet graft recovery and remodeling. In addition, significant activation of vascular endothelial growth factor in islet grafts on POD 7 correlated with development of massive newly formed microvessels, whose maturation is advanced on POD 14 with gradual diminution of HIF-1alpha. We conclude that (1) transplanted islets strongly express HIF-1alpha in association with beta-cell death and decreased insulin production until adequate revascularization is established and (2) early suppression of HIF-1alpha results in less beta-cell death thereby minimizing early graft failure. 相似文献
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T. M. Cook K. El-Boghdadly B. McGuire A. F. McNarry A. Patel A. Higgs 《Anaesthesia》2020,75(6):785-799
Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies. 相似文献
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Ghafar MA Anastasiadis AG Chen MW Burchardt M Olsson LE Xie H Benson MC Buttyan R 《The Prostate》2003,54(1):58-67
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Banham AH Boddy J Launchbury R Han C Turley H Malone PR Harris AL Fox SB 《The Prostate》2007,67(10):1091-1098
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M. Z. Akhtar A. I. Sutherland H. Huang C. W. Pugh 《American journal of transplantation》2014,14(7):1481-1487
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Disorders of the lymph circulation: their relevance to anaesthesia and intensive care 总被引：7，自引：0，他引：7
The lymphatic system is known to perform three major functionsin the body: drainage of excess interstitial fluid and proteinsback to the systemic circulation; regulation of immune responsesby both cellular and humoral mechanisms; and absorption of lipidsfrom the intestine. Lymphatic disorders are seen following malignancy,congenital malformations, thoracic and abdominal surgery, trauma,and infectious diseases. They can occasionally cause mortality,and frequently morbidity and cosmetic disfiguration. Many lymphaticdisorders are encountered in the operating theatre and criticalcare settings. Disorders of the lymphatic circulation relevantto anaesthesia and intensive care medicine are discussed inthis review. Br J Anaesth 2003; 91: 265–72 相似文献
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Recent studies have shown that nasal oxygen delivery can prolong the time to desaturation during apnoea in the non‐pregnant population. We investigated the benefits of apnoeic oxygenation during rapid sequence induction in the obstetric population using computational modelling. We used the Nottingham Physiology Simulator, and pre‐oxygenated seven models of pregnancy for 3 min using FiO2 1.0, before inducing apnoea. We found that increasing FiO2 at the open glottis increased the time to desaturation, extending the time taken for SaO2 to reach 40% from 4.5 min to 58 min in the average parturient model (not in labour). Our study suggests that a small increase in time to desaturation could be achieved at FiO2 0.4–0.6, which could be delivered by standard nasal cannulae. The greatest increases in time to desaturation were seen at FiO2 1.0, which could be delivered by high‐flow nasal cannulae under ideal conditions. 相似文献
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C.L.M. Tay MMED S''PORE G.M. Tan FFARCSI & S.B.A. Ng MMED S''PORE 《Paediatric anaesthesia》2001,11(6):711-718
BACKGROUND: We undertook an audit of paediatric perioperative incidents in the first 10000 anaesthetics administered in KK Women's and Children's Hospital in Singapore between May 1997 and April 1999. The spectrum of surgery performed ranged from simple ambulatory surgery to open heart surgery for complicated congenital heart diseases. METHODS: An audit form is completed for every anaesthetic delivered and critical incidents are reported on the reverse blank page of the audit form. An anaesthetic incident was defined as 'any incident which affected, or could have affected, the safety of the patient under anaesthetic care'. RESULTS: Two hundred and ninety-seven critical incidents were reported. The majority of them happened in healthy patients (80.1% ASA I and II) scheduled for elective surgery (73.3%). Critical incidents in infants less than 1 year of age were four times as common as in older children (8.6% versus 2.1%). Incidents occurred mainly during maintenance (80.6%). There was no anaesthetic mortality. Respiratory events were the most common (77.4%) with laryngospasm accounting for 35.7%. Cardiovascular incidents (10.8%) included hypotension from haemorrhage and sepsis, and dysrhythmias. The incidence of equipment and pharmacologically related problems was low. CONCLUSIONS: Future reviews of a larger patient population may be helpful to determine trends of perioperative events and whether quality assurance programs have made a difference. 相似文献
