- Email: [email protected]
Something for everyone
Trends in Anaesthesia and Critical Care 3 (2013) 1–2
Contents lists available at SciVerse ScienceDirect
Trends in Anaesthesia and Critical Care journal homepage: www.elsevier.com/locate/tacc
EDITORIAL
Something for everyone
In this, the first issue of 2013, our third year of publication, we have something for everyone. Thinking back over the last 35 years (yes, I have been giving anaesthetics since 1978), the amount of information which we all need to process every day is now immense. It seemed to be considerable in the 1970s, but it must now be many times greater. It is, of course, simultaneously helped and made worse by the electronic age – helped because access to the information is in many cases easier, but made worse by the explosion of information available. “‘Ready?’ She said breathlessly. ‘What are we doing?’ Harry said, completely lost. Hermione turned the hourglass over three times. The dark ward dissolved. ...... ‘What – how – Hermione what happened?’ ‘We’ve gone back in time’ Hermione whispered”1 I guess that one solution to the information explosion would be to supply us all with time turners, just like Hermione Granger’s. We would be able to spend 3 h reading articles on one subject then return to the starting point in time and address another subject. But presently time turners seem to be in short supply. This issue of TACC does not come with a free time turner unfortunately but reading it will help. We have a diverse array of useful information in this issue and a great deal more lined up for the remainder of 2013. Smoking has long been a subject of debate amongst members of the medical profession and especially anaesthesiologists. We all well known the potential for an increase in perioperative complications in patients who smoke and should take the opportunity at the preoperative visit to give objective advice and try to encourage patients to quit. Canet in this issue does point out some comforting advice in that patients facing surgery are more likely to stop smoking permanently. He also reminds us of the perioperative dangers of passive smoking to children of smokers. Obesity has been referred to as an epidemic of the 21st Century in parts of the western world. Every anaesthesiologist will therefore meet obese patients on an operating list. More extremes of obesity carry additional complications and may be better managed in centres which have developed particular expertise in this area. One such problem is difficulties with respiration and ventilation. Soriano in this issue takes us through the background physiology and links it to ventilatory management in the morbidly obese patient. The body temperature of our patients has been regarded as important for many decades and greater focus on the benefit of maintaining it at the correct level seem to have been growing 2210-8440/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tacc.2013.01.001
recently. Anaesthesia blunts the patient’s inbuilt temperature maintenance so surely we need to monitor it as a part of our routine practice in maintaining our patients’ wellbeing. How should we measure it though? Kimberger describes the various routes and techniques open to us and outlines their accuracy. It might therefore be considered surprising that measurement of such a fundamental physiological process as body temperature is not included as a part of routine minimal monitoring for every patient. After all, the technology is readily available in every operating room. Should monitoring the depth of anaesthesia also be a part of minimal monitoring? Some would argue that this has been the case since the dawn of anaesthesia. Guedel described his signs of anaesthesia which have been adapted and developed over the ensuing decades such that they now form a central part of the ‘art’ of anaesthesia. But what about some objective monitoring? Monitors based on processed EEG have been investigated for many years and the best-known one currently is the BIS monitor. Avidan and his co-workers have a great deal of experience in this area and summarise the present situation with respect to this most interesting topic. Certain individual conditions present a challenge for anaesthesia and the various manifestations of inflammatory arthritis are high on this list. The rigid “bamboo” spine of ankylosing spondylitis makes central neuraxial blocks extremely difficult and in many cases impossible. Other joints and vital organs may be affected in addition, including the airway, and this whole issue is explored by Arora and colleagues. We have come a long way since the local analgesia properties of cocaine were discovered and harnessed for clinical benefit. Local anaesthetic agents now form a routine part of modern anaesthesia and analgesia. They are routinely used not only for surgical procedures but also increasingly as a strategy to provide improved postoperative analgesia for our patients. These drugs, like most others, do have the potential for adverse toxic effects though and in the case of the local analgesics, may be manifest at the local level and also at the systemic level. Significant morbidity has been reported and also mortality from systemic toxicity. The scale of the problem and mechanisms involved are described in the article by Byrne and Engelbrecht. Intracerebral haemorrhage is devastating to the patient and his/ her family. It also impinges significantly on society and the health service. Despite a great deal of research, the outcome remains uncertain in many cases. Systemic hypertension is one contributory factor to the bleed in the first place but also the acute event is often followed by a hypertensive response which can worsen the prognosis by an increase in the incidence of rebleeding. Early treatment with antihypertensive agents may ameliorate this problem
2
Editorial / Trends in Anaesthesia and Critical Care 3 (2013) 1–2
and improve outcome but the optimum management has not yet been determined. This issue is debated by De Robertis and colleagues in this issue of TACC. It has long been appreciated that in sepsis large fluid volumes may be required for infusion in order to provide adequate resuscitation. Indeed, fluid therapy remains a central plank of management but recently data has begun to accumulate to suggest that the use of hypertonic fluids might be more beneficial that isotonic ones. Van Harn, in this issue of TACC, examines our current knowledge of this topic and looks at where we need to go next to see if this will improve management of our septic patients. One of the difficulties with liver transplantation has always been the severe coagulation derangements which accompany the surgery. Pre-existing coagulopathy is commonly present and frequent monitoring of coagulation status (including platelet function) is crucial in these patients. Not only that but the result must be available rapidly – there is no place for sending samples to a central laboratory facility which provides the result an hour or so later. A number of machines have been developed to bring coagulation
testing to the patient on the ward and in the operating room and these are reviewed by Agarwal and colleagues. In this issue of TACC there is thus something for everyone. We have had a great deal of satisfaction in assembling this selection and trust that you will gain a great deal from reading it. But looking further into the future, our aim is to provide useful information for you, our readers, so if there are any topics which you wish to see reviewed, please let us know and we will endeavour to provide them for you. Reference 1. Rowling JK. Harry Potter and the prisoner of Azkaban. Bloomsbury Publishing PLC; 1999. p. 288–9.
Brian Pollard Manchester Medical School, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom 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
Something for everyone
In this, the first issue of 2013, our third year of publication, we have something for everyone. Thinking back over the last 35 years (yes, I have been giving anaesthetics since 1978), the amount of information which we all need to process every day is now immense. It seemed to be considerable in the 1970s, but it must now be many times greater. It is, of course, simultaneously helped and made worse by the electronic age – helped because access to the information is in many cases easier, but made worse by the explosion of information available. “‘Ready?’ She said breathlessly. ‘What are we doing?’ Harry said, completely lost. Hermione turned the hourglass over three times. The dark ward dissolved. ...... ‘What – how – Hermione what happened?’ ‘We’ve gone back in time’ Hermione whispered”1 I guess that one solution to the information explosion would be to supply us all with time turners, just like Hermione Granger’s. We would be able to spend 3 h reading articles on one subject then return to the starting point in time and address another subject. But presently time turners seem to be in short supply. This issue of TACC does not come with a free time turner unfortunately but reading it will help. We have a diverse array of useful information in this issue and a great deal more lined up for the remainder of 2013. Smoking has long been a subject of debate amongst members of the medical profession and especially anaesthesiologists. We all well known the potential for an increase in perioperative complications in patients who smoke and should take the opportunity at the preoperative visit to give objective advice and try to encourage patients to quit. Canet in this issue does point out some comforting advice in that patients facing surgery are more likely to stop smoking permanently. He also reminds us of the perioperative dangers of passive smoking to children of smokers. Obesity has been referred to as an epidemic of the 21st Century in parts of the western world. Every anaesthesiologist will therefore meet obese patients on an operating list. More extremes of obesity carry additional complications and may be better managed in centres which have developed particular expertise in this area. One such problem is difficulties with respiration and ventilation. Soriano in this issue takes us through the background physiology and links it to ventilatory management in the morbidly obese patient. The body temperature of our patients has been regarded as important for many decades and greater focus on the benefit of maintaining it at the correct level seem to have been growing 2210-8440/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tacc.2013.01.001
recently. Anaesthesia blunts the patient’s inbuilt temperature maintenance so surely we need to monitor it as a part of our routine practice in maintaining our patients’ wellbeing. How should we measure it though? Kimberger describes the various routes and techniques open to us and outlines their accuracy. It might therefore be considered surprising that measurement of such a fundamental physiological process as body temperature is not included as a part of routine minimal monitoring for every patient. After all, the technology is readily available in every operating room. Should monitoring the depth of anaesthesia also be a part of minimal monitoring? Some would argue that this has been the case since the dawn of anaesthesia. Guedel described his signs of anaesthesia which have been adapted and developed over the ensuing decades such that they now form a central part of the ‘art’ of anaesthesia. But what about some objective monitoring? Monitors based on processed EEG have been investigated for many years and the best-known one currently is the BIS monitor. Avidan and his co-workers have a great deal of experience in this area and summarise the present situation with respect to this most interesting topic. Certain individual conditions present a challenge for anaesthesia and the various manifestations of inflammatory arthritis are high on this list. The rigid “bamboo” spine of ankylosing spondylitis makes central neuraxial blocks extremely difficult and in many cases impossible. Other joints and vital organs may be affected in addition, including the airway, and this whole issue is explored by Arora and colleagues. We have come a long way since the local analgesia properties of cocaine were discovered and harnessed for clinical benefit. Local anaesthetic agents now form a routine part of modern anaesthesia and analgesia. They are routinely used not only for surgical procedures but also increasingly as a strategy to provide improved postoperative analgesia for our patients. These drugs, like most others, do have the potential for adverse toxic effects though and in the case of the local analgesics, may be manifest at the local level and also at the systemic level. Significant morbidity has been reported and also mortality from systemic toxicity. The scale of the problem and mechanisms involved are described in the article by Byrne and Engelbrecht. Intracerebral haemorrhage is devastating to the patient and his/ her family. It also impinges significantly on society and the health service. Despite a great deal of research, the outcome remains uncertain in many cases. Systemic hypertension is one contributory factor to the bleed in the first place but also the acute event is often followed by a hypertensive response which can worsen the prognosis by an increase in the incidence of rebleeding. Early treatment with antihypertensive agents may ameliorate this problem
2
Editorial / Trends in Anaesthesia and Critical Care 3 (2013) 1–2
and improve outcome but the optimum management has not yet been determined. This issue is debated by De Robertis and colleagues in this issue of TACC. It has long been appreciated that in sepsis large fluid volumes may be required for infusion in order to provide adequate resuscitation. Indeed, fluid therapy remains a central plank of management but recently data has begun to accumulate to suggest that the use of hypertonic fluids might be more beneficial that isotonic ones. Van Harn, in this issue of TACC, examines our current knowledge of this topic and looks at where we need to go next to see if this will improve management of our septic patients. One of the difficulties with liver transplantation has always been the severe coagulation derangements which accompany the surgery. Pre-existing coagulopathy is commonly present and frequent monitoring of coagulation status (including platelet function) is crucial in these patients. Not only that but the result must be available rapidly – there is no place for sending samples to a central laboratory facility which provides the result an hour or so later. A number of machines have been developed to bring coagulation
testing to the patient on the ward and in the operating room and these are reviewed by Agarwal and colleagues. In this issue of TACC there is thus something for everyone. We have had a great deal of satisfaction in assembling this selection and trust that you will gain a great deal from reading it. But looking further into the future, our aim is to provide useful information for you, our readers, so if there are any topics which you wish to see reviewed, please let us know and we will endeavour to provide them for you. Reference 1. Rowling JK. Harry Potter and the prisoner of Azkaban. Bloomsbury Publishing PLC; 1999. p. 288–9.
Brian Pollard Manchester Medical School, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom E-mail address: [email protected]