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Practical advice for the practising clinician
Trends in Anaesthesia and Critical Care 2 (2012) 257
Contents lists available at SciVerse ScienceDirect
Trends in Anaesthesia and Critical Care journal homepage: www.elsevier.com/locate/tacc
EDITORIAL
Practical advice for the practising clinician This issue of Trends in Anaesthesia and Critical Care (TACC) marks the end of our second year in publication. We have a number of articles in this issue which give useful and practical advice for the practising anaesthesiologist and intensivist ranging from allergic reactions, airways and ventilation to nerve blocks, renal disease in pregnancy and resuscitation. The words ‘allergic reaction’ are often misused although everybody seems to know what they mean. As a catch-all phrase, they encompass a whole range of unexpected reactions ranging from the almost inconsequential to the serious and life-threatening. In the fields of Anaesthesia and Critical care, the most common reasons for such reactions are the drugs which we use although other potential sources include latex and other contact substances. It is probably true to say that any of the agents which we might administer may cause an allergic reaction although certain families of drugs are more common culprits than others. What is important is to alert the patient to the situation after the event to ensure that they understand that they should avoid exposure to this agent or family ever again. Amongst the drugs which we use, the neuromuscular blocking agents are reported to be the family involved most often. Reactions to some other agents, in particular the antibiotics, are also relatively common. Allergy to agents used every day such as chlorhexidine appears to be developing and increasing. I had never heard of chlorhexidine allergy when I was in training but that was over 3 decades ago. But is that because we are recognising reactions more often now? A short-lived episode of hypotension or mild bronchospasm may be dismissed as a ‘normal’ part of the process of anaesthesia whereas in reality perhaps it was a manifestation of a mild allergic reaction. We cannot investigate every episode of hypotension in case it was a mild allergic reaction – or can we? Reacquainting ourselves with the correct way to identify allergic reactions can only be of value. Dr Savic and colleagues provide a very valuable update on this situation in this issue. Manipulation of the airway is fundamental to the practice of anaesthesia. Over the decades, a great many devices have been described to assist us in this process. We cannot just have bright ideas and develop such devices in our garden sheds though. There is a process which must be carefully followed in order to ensure that any new device is fit for purpose and above all safe to use in our patients. This process is outlined by Dr Cook. Parallel with airway manipulations of course is the conduct of controlled ventilation. The management of controlled ventilation in the operating room has changed markedly over the last 10 years. Sorry to reminisce again, but when I was in training, there seemed to be very little attention paid to the mode of ventilation – provided an adequate minute volume was given so as to prevent hypoxia and hypercapnia then it was satisfactory. Recent evidence now suggests that, in particular, choice of tidal volume, inspired oxygen fraction and the use of PEEP in the operating room are far more important 2210-8440/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tacc.2012.10.003
than we had believed. This is clearly very important for our patients and Dr Ferrando in this issue outlines these latest thoughts. Many surgical procedures can be performed under a nerve block and in some countries regional blocks are the preferred means of providing optimum conditions for surgery rather than general anaesthesia. It is probably fair to say that almost any nerve in the body can be blocked if needed. When I was training, I was taught the landmark method and a great many books have been written over the years describing these various methods and their variants. Accessing the nerve to inject the local anaesthetic solution as close as possible to it is only a part of the story though. Avoiding other important structures (e.g. arteries, veins, viscera) is just as important. The availability of simple ultrasound machines has changed all of that, allowing us to visualise the nerve and its surrounding structures so that we can apply the local anaesthetic accurately and avoid many of the complications. Sakura and colleagues examine the present evidence concerning the use of ultrasound guidance for performing peripheral nerve blocks. Ultrasound can also be used to assist in central nerve (neuraxial) blocks. Central nerve blocks are, in many centres, the technique of choice for caesarean delivery in the pregnant woman. The reasons behind this choice of technique have been well described and discussed in many forums. In this issue of TACC, Baidya and colleagues reinforce this choice and extend it to describe the advantages in the pregnant parturient with renal disease. The effects of renal disease on pregnancy and the peripartum period are also included. Cardiopulmonary resuscitation is one of the key skills which every medical practitioner should be taught and in which they should undergo regular refreshers. Recommendations for the most effective techniques are constantly being re-evaluated and are disseminated regularly by the relevant bodies in various countries. But what is the evidence behind these guidelines and the definitions of good quality CPR? Can we get any assistance in providing the best quality of training and delivery? In this issue Gruber and colleagues examine some aspects of this evidence with particular emphasis on the feedback devices designed for use by providers during a cardiac arrest situation. This issue of TACC thus contains a great deal of practical guidance to end our second year. We hope that you enjoy reading this issue and are looking forward to next year. May I take this opportunity to wish every reader the compliments of the festive season and a wish for a prosperous New Year. Brian Pollard* University Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom * Tel.: þ44 161 276 8650; fax: þ44 161 273 5685. E-mail address: [email protected].
Contents lists available at SciVerse ScienceDirect
Trends in Anaesthesia and Critical Care journal homepage: www.elsevier.com/locate/tacc
EDITORIAL
Practical advice for the practising clinician This issue of Trends in Anaesthesia and Critical Care (TACC) marks the end of our second year in publication. We have a number of articles in this issue which give useful and practical advice for the practising anaesthesiologist and intensivist ranging from allergic reactions, airways and ventilation to nerve blocks, renal disease in pregnancy and resuscitation. The words ‘allergic reaction’ are often misused although everybody seems to know what they mean. As a catch-all phrase, they encompass a whole range of unexpected reactions ranging from the almost inconsequential to the serious and life-threatening. In the fields of Anaesthesia and Critical care, the most common reasons for such reactions are the drugs which we use although other potential sources include latex and other contact substances. It is probably true to say that any of the agents which we might administer may cause an allergic reaction although certain families of drugs are more common culprits than others. What is important is to alert the patient to the situation after the event to ensure that they understand that they should avoid exposure to this agent or family ever again. Amongst the drugs which we use, the neuromuscular blocking agents are reported to be the family involved most often. Reactions to some other agents, in particular the antibiotics, are also relatively common. Allergy to agents used every day such as chlorhexidine appears to be developing and increasing. I had never heard of chlorhexidine allergy when I was in training but that was over 3 decades ago. But is that because we are recognising reactions more often now? A short-lived episode of hypotension or mild bronchospasm may be dismissed as a ‘normal’ part of the process of anaesthesia whereas in reality perhaps it was a manifestation of a mild allergic reaction. We cannot investigate every episode of hypotension in case it was a mild allergic reaction – or can we? Reacquainting ourselves with the correct way to identify allergic reactions can only be of value. Dr Savic and colleagues provide a very valuable update on this situation in this issue. Manipulation of the airway is fundamental to the practice of anaesthesia. Over the decades, a great many devices have been described to assist us in this process. We cannot just have bright ideas and develop such devices in our garden sheds though. There is a process which must be carefully followed in order to ensure that any new device is fit for purpose and above all safe to use in our patients. This process is outlined by Dr Cook. Parallel with airway manipulations of course is the conduct of controlled ventilation. The management of controlled ventilation in the operating room has changed markedly over the last 10 years. Sorry to reminisce again, but when I was in training, there seemed to be very little attention paid to the mode of ventilation – provided an adequate minute volume was given so as to prevent hypoxia and hypercapnia then it was satisfactory. Recent evidence now suggests that, in particular, choice of tidal volume, inspired oxygen fraction and the use of PEEP in the operating room are far more important 2210-8440/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tacc.2012.10.003
than we had believed. This is clearly very important for our patients and Dr Ferrando in this issue outlines these latest thoughts. Many surgical procedures can be performed under a nerve block and in some countries regional blocks are the preferred means of providing optimum conditions for surgery rather than general anaesthesia. It is probably fair to say that almost any nerve in the body can be blocked if needed. When I was training, I was taught the landmark method and a great many books have been written over the years describing these various methods and their variants. Accessing the nerve to inject the local anaesthetic solution as close as possible to it is only a part of the story though. Avoiding other important structures (e.g. arteries, veins, viscera) is just as important. The availability of simple ultrasound machines has changed all of that, allowing us to visualise the nerve and its surrounding structures so that we can apply the local anaesthetic accurately and avoid many of the complications. Sakura and colleagues examine the present evidence concerning the use of ultrasound guidance for performing peripheral nerve blocks. Ultrasound can also be used to assist in central nerve (neuraxial) blocks. Central nerve blocks are, in many centres, the technique of choice for caesarean delivery in the pregnant woman. The reasons behind this choice of technique have been well described and discussed in many forums. In this issue of TACC, Baidya and colleagues reinforce this choice and extend it to describe the advantages in the pregnant parturient with renal disease. The effects of renal disease on pregnancy and the peripartum period are also included. Cardiopulmonary resuscitation is one of the key skills which every medical practitioner should be taught and in which they should undergo regular refreshers. Recommendations for the most effective techniques are constantly being re-evaluated and are disseminated regularly by the relevant bodies in various countries. But what is the evidence behind these guidelines and the definitions of good quality CPR? Can we get any assistance in providing the best quality of training and delivery? In this issue Gruber and colleagues examine some aspects of this evidence with particular emphasis on the feedback devices designed for use by providers during a cardiac arrest situation. This issue of TACC thus contains a great deal of practical guidance to end our second year. We hope that you enjoy reading this issue and are looking forward to next year. May I take this opportunity to wish every reader the compliments of the festive season and a wish for a prosperous New Year. Brian Pollard* University Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom * Tel.: þ44 161 276 8650; fax: þ44 161 273 5685. E-mail address: [email protected].