Preoperative risk stratification of critically ill patients

Copeland, C.C. et al. (2017) The Journal of Clinical Anesthesia. 39 (June) pp. 122–127

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Highlights:

  • Preoperative assessment of critically ill patients is challenging and understudied.
  • ASA class, RCRI, and SOFA score were studied to predict survival to discharge.
  • One in four ICU patients did not survive to discharge after an intervention.
  • Available scores inadequately discriminated between survivors and non-survivors.
  • SOFA score (AUC = 0.68) outperformed ASA class (AUC = 0.59).

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Pain Assessment in INTensive care (PAINT)

Kemp, H.I. et al. Anaesthesia. Published online: 19 February 2017

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines.

The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.

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Antibiotic therapy in critically ill patients

Martin-Loeches, I. et al. European Journal of Anaesthesiology. Published online: 30  January 2017

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.

At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.

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Care of the eye during anaesthesia and intensive care

 O’Driscoll, A. & White, E. Anaesthesia and Intensive Care Medicine. Published online: November 26 2016

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Image source: Dianne Harris – Wellcome Images // CC BY-NC-ND 4.0

Perioperative eye injuries and blindness are rare but important complications of anaesthesia. The three causes of postoperative blindness are ischaemic optic neuropathy, central retinal artery thrombosis (these can exist in tandem and have been described as ischaemic oculopathies) and cortical blindness.

This review aims to improve anaesthetists’ knowledge of orbital anatomy, ocular physiology and the mechanisms of perioperative eye injuries to help reduce their occurrence.

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Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial

Kelly, S.J. et al. (2016) Anaesthesia. 71. pp. 1153-62

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Introduction: Reports in the literature have suggested that paracetamol is associated with significant hypotension, a potentially important interaction for labile critically ill patients. These authors carried out a single-centre, prospective, open-label, randomised, parallel-arm, active-control trial, designed to determine the incidence of hypotension following the administration of paracetamol to critically ill patients.

Methods: A total of 50 adult patients receiving paracetamol for analgesia or pyrexia were randomly assigned to receive either the parenteral or enteral formulation of the drug. Paracetamol concentrations were measured at baseline and at multiple time points over 24 hours.

Results: The maximal plasma paracetamol concentration was significantly different between routes; 156 versus 73 µmol/L (p=0.0005) following the first dose of parenteral or enteral paracetamol, respectively. Sixteen hypotensive events occurred in 12 patients: parenteral n=12; enteral n=4. The incident rate ratio for parenteral versus enteral paracetamol was 2.94 (95% confidence interval 0.97 to 8.92; p=0.06).

Conclusions: The authors conclude that the incidence of hypotension associated with paracetamol administration is higher than previously reported and tends to be more frequent with parenteral paracetamol.

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Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care

Heiberg, J. et al. (2016). Anaesthesia. Volume 71(9). pp. 1091–1100

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Image source: Patrick J. Lynch, medical illustrator – Wikipedia // CC BY 2.5

Image shows illustration of transesophageal echocardiography ultrasound diagram

Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management.

We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

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