British journal of anaesthesia
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Correct diagnostic management of perioperative hypersensitivity aims to identify the underlying mechanism(s), responsible culprit(s), and safe alternative drugs or techniques. Although drug provocation tests are considered the gold standard, diagnosis of perioperative hypersensitivity mainly relies on skin testing. Use of in vitro tests, such as quantification of specific immunoglobulin E antibodies, serum tryptase, and plasma histamine, as well as basophil activation tests is becoming widespread. ⋯ In this narrative review, we summarise the principles of these in vitro tests, and the possibilities and limitations when these tests are used for testing sensitivity to substances with a high risk of causing perioperative hypersensitivity. Hence, we focus on neuromuscular blocking agents, antibiotics, natural rubber latex, and opiates/opioids. The combination of multiple tests would allow diagnosis of perioperative hypersensitivity with the right balance of safety and accuracy.
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Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. ⋯ EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.
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Simulation-based education is often highlighted as a method to prepare health personnel to handle clinical emergencies through repeated training and the design of supports. As one of the most common clinical emergencies in anaesthesia, anaphylaxis is often included in simulation scenarios at both graduate and postgraduate levels. Case reviews of anaphylaxis management continue to identify deficiencies in clinical responses. ⋯ We found evidence that in situ simulation and use of cognitive aids lead to improved teamwork and task performace. Quantitative and qualitative evidence for simulation-based perioperative training is limited. Future studies should investigate whether simulation training in perioperative anaphylaxis, particularly in situ simulation, translates into improved patient management and outcomes.
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Observational Study
Grief reactions and coping strategies of trainee doctors working in paediatric intensive care.
The death of a child can have significant emotional effects on doctors responsible for their care. Trainee doctors working in the paediatric intensive care unit (PICU) may be particularly vulnerable. The aim of this study was to examine the emotional impact of, and grief reactions to, a child's death in PICU trainee doctors, along with coping strategies they used. ⋯ Paediatric deaths evoke significant grief and emotional reactions in a subset of PICU trainee doctors. Trainee PICU doctors highlighted a lack of professional support and tailored debriefs.
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Following diagnosis of neuromuscular blocking agent (NMBA) anaphylaxis, identifying safe alternatives for subsequent anaesthesia is critical. A patient with anaphylaxis to one NMBA can also have an allergic reaction to other NMBAs (cross-reactivity). Whilst drug provocation testing is standard for identifying or excluding allergy, there is significant risk. In vitro, after an allergen activates basophils, basophils express surface activation markers that can be measured by basophil activation testing (BAT). We compared cross-reactivity between NMBAs assessed by BAT against that by skin testing. ⋯ The utility of BAT in identifying safe NMBAs for subsequent anaesthesia needs further evaluation. BAT detects a different cross-reactivity profile to skin tests. Negative skin testing and BAT might increase confidence in performing drug provocation testing, but this and follow-up of subsequent anaesthesia in our cohort is necessary to determine the clinical significance of BAT sensitisation.