Anaesthesia and intensive care
-
Anaesth Intensive Care · Nov 2015
Deviation from accepted drug administration guidelines during anaesthesia in twenty highly realistic simulated cases.
Deviations from accepted practice guidelines and protocols are poorly understood, yet some deviations are likely to be deliberate and carry potential for patient harm. Anaesthetic teams practice in a complex work environment and anaesthetists are unusual in that they both prescribe and administer the drugs they use, allowing scope for idiosyncratic practise. We aimed to better understand the intentions underlying deviation from accepted guidelines during drug administration in simulated cases. ⋯ Underlying reasons for deviations included a strong sense of clinical autonomy, poor clinical relevance and a lack of evidence for guidelines, ingrained habits learnt in early training, and the influence of peers. Guidelines are important in clinical practice, yet self-identified deviation from accepted guidelines was common in our results, and all but one of these events was judged to carry potential for patient harm. A better understanding of the reasons underlying deviation from accepted guidelines is essential to the design of more effective guidelines and to achieving compliance.
-
Anaesth Intensive Care · Nov 2015
High-risk residual gastric content in fasted patients undergoing gastrointestinal endoscopy: a prospective cohort study of prevalence and predictors.
In this prospective cohort study, we examined the residual gastric contents of 255 fasted patients undergoing gastrointestinal endoscopy. The volume and pH of residual gastric contents collected by suction under direct visualisation during gastroscopy were accurately quantified. All patients completed the minimum two-hour fast for clear fluids and 97.2% of patients completed the minimum six-hour fast for solids. ⋯ The odds of having high-risk residual gastric content were reduced with increase in age (adjusted odds ratio 0.77, 95% CI 0.61 to 0.96, P=0.0230), and use of a proton pump inhibitor or histamine type 2 receptor antagonist (adjusted odds ratio 0.24, 95% CI 0.10 to 0.55, P=0.0013), and were increased in male patients (adjusted odds ratio 2.36, 95% CI 1.06 to 5.28, P=0.0348). Notably, residual gastric content was classified as high-risk in 20.4% of patients who did not take a proton pump inhibitor or histamine type 2 receptor antagonist versus only 5.6% of those who did. Our findings suggest that, despite currently recommended fasting, males presenting for endoscopy are more likely to have high-risk gastric content than females, and that the incidence appears to be reduced with increasing age, and by the use of proton pump inhibitors or histamine type 2 receptor antagonists, we were unable to confirm or exclude an effect of body mass index, peptic pathology, diabetes or other clinical or demographic factors in our study population.
-
Anaesth Intensive Care · Nov 2015
Characteristics and expectations of fluid bolus therapy: a bi-national survey of acute care physicians.
There is little consensus on the definition or optimal constituents of fluid bolus therapy (FBT), and there is uncertainty regarding its physiological effects. The aims of this study were to determine clinician-reported definitions of FBT and to explore the physiological responses clinicians expect from such FBT. In June and October 2014, intensive care and emergency physicians in Australia and New Zealand were asked to participate in an electronic questionnaire of the reported practice and expectations of FBT. ⋯ Substantial variation was demonstrated in the magnitude of expected response within both specialties for each variable. Major variations exist in self-reported FBT practice, both within and between acute specialties, and wide variation can be demonstrated in the expected physiological responses to FBT. International explorations of practice and prospective quantification of the actual physiological response to FBT are warranted.
-
Anaesth Intensive Care · Nov 2015
Observational StudyIdiopathic interstitial pneumonia in the ICU: an observational cohort.
In the absence of a clearly identifiable cause, the prognosis of patients with interstitial lung disease is grim. This study describes our institutional experience in management of patients who are admitted to an ICU with respiratory insufficiency secondary to idiopathic interstitial pneumonia (IIP). This study was performed to obtain Australian data on patients admitted to an ICU with respiratory insufficiency secondary to IIP. ⋯ No significant difference was observed between admission characteristics and mortality. Patients admitted to ICU with respiratory failure secondary to IIP are aggressively investigated and treated, but still have a high mortality rate. Accurate predictors of mortality would be useful in offering aggressive treatment to patients who would benefit from it.
-
Anaesth Intensive Care · Nov 2015
Case ReportsHereditary antithrombin III deficiency and neuraxial anaesthesia.
Antithrombin III (ATIII) deficiency offers unique challenges to the anaesthetist in the perioperative setting due to the inherent thrombophilia, the anticoagulant therapies instituted and replacement of the deficient intrinsic natural anticoagulant. A particular challenge is the use of intrathecal anaesthesia, which requires a safe level of coagulation at the time of subarachnoid puncture. ⋯ The patient sustained no thrombotic or bleeding events. Our experience suggests that ATIII deficiency does not preclude the use of regional anaesthetic techniques so long as there is timely referral to a multidisciplinary perioperative service for anticoagulant management and that ATIII concentrate is used to ensure safe levels of ATIII throughout the perioperative period.