Anaesthesia and intensive care
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Anaesth Intensive Care · Nov 2012
Approaching families for organ donation-intensivists' perspectives.
In Australia the initial approach to families for organ donation is almost always undertaken by intensivists. There is, however, a paucity of literature on intensivists' views on this approach and how their approach compares with recommendations in published literature on this subject. This study consisted of a survey of the views of intensive care consultants and senior intensive care registrars in the four major teaching hospitals in Perth, Western Australia, on how they approached families for organ donation. ⋯ The survey results indicate that most intensive care consultants felt adequately trained to approach families for organ donation, but almost half of the group surveyed would prefer a collaborative approach with either a donor co-ordinator or a colleague with additional training on this subject. Despite recommendations in the literature and from the Australian and New Zealand Intensive Care Society to determine the registration status of potential donors on the Australian Organ Donation Registry prior to discussions with families, this was not always undertaken. In addition, the benefits of organ donation were not always discussed with families, nor were the reasons for refusal of consent sensitively explored.
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Anaesth Intensive Care · Nov 2012
Point-of-care testing of coagulation and fibrinolytic status during postpartum haemorrhage: developing a thrombelastography®-guided transfusion algorithm.
Thrombelastography® is a monitor of coagulation and fibrinolytic status, with point-of-care applications in managing haemorrhaging patients. Advocates have suggested a possible role in managing obstetric haemorrhage. This study aims to develop a pregnancy-specific thrombelastography-guided transfusion algorithm, which could be integrated into the management of postpartum haemorrhage. ⋯ From the assay-specific reference intervals obtained, it was possible to establish a pregnancy-specific thrombelastography-guided transfusion algorithm. Specific features of this transfusion algorithm included the preferential use of activated assays, the need for duplicates and a recommendation that an initial baseline thrombelastography measurement is established for subsequent serial comparisons. This transfusion algorithm has been developed to assist with assessment of coagulation and fibrinolytic status during postpartum haemorrhage.
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Anaesth Intensive Care · Nov 2012
Uptake of guidelines in the management of patients taking anticoagulants and antiplatelet agents presenting for elective surgery.
Management guidelines for patients on antithrombotic agents presenting for surgery have long been disseminated. Clinical practice, however, does not always follow published guidelines in a timely manner, despite their dissemination. This project is an audit of the management of patients on anticoagulants or antiplatelet agents presenting for elective surgery in a large metropolitan teaching hospital. ⋯ Data was collected for the 102 patients who fulfilled the inclusion criteria: 55.4% of decisions by surgeons and 51.4% of decisions by anaesthetists made in this study matched guidelines; 31.4% of decisions made by anaesthetists were fully compliant with guidelines; 20% of anaesthetic decisions were unintentionally compliant and 48.6% of anaesthetic decisions were noncompliant. A variety of reasons were cited for decisions made without the use of guidelines such as other clinical imperatives, lack of guideline awareness and a belief that it is not the role of the anaesthetist to manage perioperative antithrombotic therapy, amongst others. It is evident from this audit that compliance with guidelines remains an area where there is an opportunity for further practice improvement.
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Anaesth Intensive Care · Nov 2012
Randomized Controlled Trial Comparative StudyA pilot study of cerebral and haemodynamic physiological changes during sedation with dexmedetomidine or propofol in patients with acute brain injury.
Sedation for the mechanically-ventilated, brain-injured patient remains challenging. The purpose of this pilot study was to compare the cerebral physiologic effects of sedation with propofol versus dexmedetomidine in mechanically-ventilated, brain-injured patients. Using a randomised, crossover, unblinded clinical trial, we enrolled patients with severe brain injury (Glasgow Coma Score ≤8) from traumatic injury, subarachnoid haemorrhage or intracerebral haemorrhage undergoing multimodal monitoring (intracranial pressure, brain temperature, oximetry and microdialysis). ⋯ Though differences were noted in cerebral metabolic substrates (lactate/pyruvate ratio), none were statistically significant. In our pilot cohort, dexmedetomidine and propofol appear equally effective in sedating severely brain-injured patients and neither is associated with adverse physiological effects as measured by multimodal monitoring. Larger long-term studies are required to determine whether clinically favourable benefits demonstrated in the medical critical care setting also apply to this patient population.
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Anaesth Intensive Care · Nov 2012
ReviewThe meaning of acute kidney injury and its relevance to intensive care and anaesthesia.
Acute kidney injury (AKI) is the new consensus term for acute renal failure. The term describes a continuum of kidney injury, a common condition in the critically ill and after major surgery, which is associated with increased mortality. The incidence of AKI in intensive care unit patients in Australia is >30% and sepsis is a major contributory factor. ⋯ In this review, we explore the limitations of animal and human models of AKI and the implications of recent research on our current understanding of the pathophysiology of AKI. In addition, we describe conventional and novel diagnostic methods and therapies, and explore the clinical implications of the effect of fluid administration and perioperative management. Finally, we identify priorities for clinical investigations and future directions in AKI research.