围手术期应激性心肌病:麻醉医师应该警惕的临床危象

应激性心肌病又称Takotsubo心肌病(Takotsubo cardiomyopathy,TCM),是与应激相关、临床表现与急性心肌梗死(acute myocardial infarction,AMI)类似的循环危象。麻醉医师在围手术期遭遇TCM的情况并不少见,目前国内较少文章全面阐述这一综合征。文章就围手术期TCM的诱因、病理机制、临床特征、诊断要点、鉴别诊断和主要治疗原则进行综述,旨在为麻醉医师了解和应对该综合征提供全面的参考。     

Perioperative therapy: possibilities of rationalization

Summary. The complexity of daily clinical work requires a sophisticated collaboration of surgery and anesthesiology. This can be accomplished by a rational approach to the following topics: clear definition of areas of competence respecting the principle of mutual trust, integration of anesthesiologists into the basic physical examination, proposal of case-oriented preoperative diagnostics, agreement on necessary preoperative therapy, common consultational meetings for outpatient surgery, recovery room available 24 h a day, instruction of the surgical personnel in specific pain therapy, availability of coworkers who are competent and willing to cooperate, no unilateral renunciation of clinical knowledge, ability and execution, no renunciation of organizational and structural self-determination, no monopoly on perioperative medicine.      

The need for maternal critical care education,point-of-care ultrasound and critical care echocardiography in obstetric anesthesiologists training

Globally, the increase in medically complex obstetric patients is challenging the educational approach and clinical management of critically ill obstetric patients. This increase in medical complexity calls into question the educational paradigm in which future physicians are trained. Obstetric anesthesiologists, physician experts in the perio-perative planning and management of complex obstetric patients, represent an essential workforce in the strategies to address maternal mortality. Unfortunately, the development of peri-operative medicine and maternal critical care curricula has only received minor attention in most countries.Proposed guidelines and models highlight the existing need for tiered maternity care services in which critical care infrastructure plays a central role in the delivery of high-risk peripartum care. Therefore, the development of maternal critical care models designed to prepare obstetric anesthesiologists for the clinical challenges of a medically complex patient are warranted. Key critical care topics such as advanced ultrasonography, with the inclusion of quantitative echocardiographic assessments into obstetric anesthesiology educational curricula, will serve to better prepare physicians for the realities of an increasingly complex pregnant patient population, and further reinforce the critical care infrastructure detailed in the Levels of Maternal Care consensus.Despite an increasingly complex obstetric patient population, heterogeneity of maternal critical care practices exists across the globe, warranting standardization and further development of proposed curricula.     

The "six sigma approach" to the operating room environment and infection

The patient's external environment plays a significant, and in some cases dominant, role in his or her infection risk. The use of ultraclean air for certain procedures, as well as avoidance of hypothermia have been proven to reduce the risk of infection. There is no data to support the routine use of surgical masks (by surgeons or staff), ventilating helmets, or routine cleaning of all environmental surfaces in between cases. More research needs to be done in order to determine whether OR design changes, in addition to increasing OR efficiency and thus reducing case times, can also reduce infection rates. Further research is also needed to determine whether or not double gloves and/or the use of antiseptic scrubbing in addition to painting are efficacious.     

围手术期精准医疗有助于麻醉医师改善患者预后：β受体阻滞剂与阿片类药物的遗传变异性

随着精准医疗的不断发展,医师能够根据患者的个体遗传和分特征制定疾病的治疗和预防策略。近年来,基因测序及其相关技术在医疗机构中变得更加经济和便捷,其在各种医疗领域中的应用范围也在不断扩大。特别是在围手术期,有很多使用精准医疗的机会。例如,α和β肾上腺素能受体的个体多态性可提高β受体阻滞剂的疗效,同时也使患者容易出现药物不良反应,包括低血压和心动过缓等。同样,阿片受体的个体多态性可以使阿片类药物在术后镇痛中的有效性提高或者降低。此外,细胞色素P450 2D6(CYP2D6)酶基因的突变可以通过加速或减缓β受体阻滞剂和阿片类药物的代谢和清除,大大影响到二者的临床反应。术前基因测序可使麻醉医师识别患者上述以及其他相关的分子特征,并相应地选择适当的围手术期治疗策略,从而最大限度地提高临床疗效,减少不良事件的发生率。当下正是麻醉医师和围手术期医务人员实践精准医疗的时候。     

The operating room gown as a barrier to bacterial shedding

An evaluation of cloth, paper, and plastic surgical gowns reveals that a plastic, hooded gown reduces microbial contamination more effectively than does either cloth or paper by 71.8 and 57.3 per cent, respectively (P < 0.0005).     

Can peri-operative quality be maintained in the drive for operating room efficiency? An American perspective

Hospitals in privately (US) and publicly funded medical systems around the world are scrutinizing every aspect of the financing and delivery of surgical care. Whereas many physicians believe championing operating room efficiency will compromise quality, this is not necessarily the case. Higher quality care could be less costly because ‘defects’ (e.g. complications) and rework of products and services are avoided. The challenge is to innovate in the surgical suite and to promote efficiency and quality concurrently. This chapter discusses different definitions of quality with emphasis on the Six Sigma methodology, opportunities for cost reduction with clinical pathways and Internet-related tools and insights obtained from recently published advances in applying sophisticated analytical tools from management science to the peri-operative environment. Healthcare providers will have to use innovations in information technologies, as well as scientifically derived operating room management analytical tools, to help control costs while maintaining the quality that each ‘customer’ of the surgery suite expects.     

Cold as a therapeutic agent

Summary The use of cold as a therapeutic agent has a long and colorful history. The Edwin Smith Papyrus, the most ancient medical text known, dated 3500 B.C., made numerous references to the use of cold as therapy. Baron de Larrey, a French army surgeon during Napoleon’s Russian campaign, packed the limbs in ice prior to amputations to render the procedures painless. In the early twentieth century, a neurosurgeon, Temple Fay, pioneered “human refrigeration” as a treatment for malignancies and head injuries. In 1961, Irving Cooper developed the first closed cryoprobe system and ushered in the modern era of cryogenic surgery with his imperturbable convictions. Fay’s early work fell victim to the disruptive sequel of the World War II. The Nazis confiscated his data (presented before the Third International Cancer Congress in 1939) forwarded to Belgium for publication and brutally applied his refrigeration techniques experimentally without any benefit of anesthesia in the concentration camps, especially Dachau. Hypothermia became associated in the public mind with the atrocities exposed at the war trials in Nürnberg. After lying dormant for decades, the interest was rekindled in the late 80s when mild hypothermia was shown to confer dramatic neuroprotection in a number of experimental models of brain injury. With several large multi-center clinical studies currently under way, hypothermia is receiving unprecedented attention from the medical and scientific communities.     

Prospective comparison of the ‘inside–out’ and ‘outside–in’ transobturator-tape procedures for the treatment of female stress urinary incontinence

The aim of this study was to prospectively compare the efficacy and safety of ‘inside–out’ (TVT-O) and ‘outside–in’ (TOT) transobturator tape procedures for treatment of female stress urinary incontinence (SUI). One hundred women with SUI were alternately assigned to TVT-O (n = 50) or TOT (n = 50). About 1 year after surgery, we compared surgical outcomes in the two groups. TVT-O and TOT showed similar rates of cure (86 vs 92%). Approximately 1 year after surgery, Incontinence Quality of Life questionnaire parameters improved significantly in both groups (p < 0.05), but the two groups did not differ (p > 0.05). The rates of patient satisfaction with TVT-O and TOT (96 vs 98%) were similar. These preliminary results suggest that TVT-O and TOT are equally effective and safe procedures for women with SUI. However, this study was unable to identify a difference between the two procedures due to the underpowered nature of the study.     

Commentary: how surgical audits can be used to promote the update of surgical evidence

Evidence-based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long-term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence-practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence-uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence.     

Extension of cardiopulmonary bypass outside the operating room as a short-term bridge to recovery “the poor man’s ECMO”

This report describes the use of conventional cardiopulmonary bypass (CPB) circuit beyond the operating room to the critical care unit to provide cardiopulmonary support for patients requiring emergent resuscitation as well as short-term support for rest and recovery of the heart. We modified the CPB circuit and created a closed extra corporeal membrane oxygenation (ECMO) circuit using a conventional oxygenator excluding the venous reservoir. We believe that this technique provides a short-term mechanical support and also acts as a bridge to recovery, or a bridge to decision, in very limited resource settings.     

When might an operative complication be regarded as acceptable? Part 1: Surgical factors that influence courts when finding fault during litigation

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have reviewed recent reported cases, noting both surgical and evidential influences on outcome. Taken together, these reveal that among other influential factors, the acceptability of more than one reasonable operative approach, the court’s approach to inappropriate delegation and the uncertainties of expert evidence all play a role in the determination of the case.     

The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: a consensus guideline

This multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation.     

When might an operative complication be regarded as acceptable? Part 2: Judicial factors that influence the finding of fault during surgical litigation

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have previously reviewed reported cases where the outcome turned on actions taken by surgeons. We now turn our attention to judicial attitudes to evidence that play a role in the determination of the case.