Anaesthesia & intensive care medicine RSS feed: Current Issue. Anaesthesia and Intensive Care Medicine , an invaluable source of up-to-date information, with the curriculum of both the Primary and Final FRCA examinations covered over a three-year cycle. Published monthly this ever-updating text book will be an invaluable source for both trainee and experienced anaesthetists. The enthusiastic editorial board, under the guidance of two eminent and experienced series editors, ensures Anaesthesia and Intensive Care Medicine covers all the key topics in a comprehensive and authoritative manner. Articles now include learning objectives and eash issue features MCQs, facilitating self-directed learning and enabling readers at all levels to test their knowledge. Each issue is divided between basic scientific and clinical sections. The basic science articles include anatomy, physiology, pharmacology, physics and clinical measurement, while the clinical sections cover anaesthetic agents and techniques, assessment and perioperative management. Further sections cover audit, trials, statistics, ethical and legal medicine, and the management of acute and chronic pain. http://www.anaesthesiajournal.co.uk/?rss=yesElsevier Inc.en © 2012 Published by Elsevier Inc. All rights reserved. Anaesthesia & intensive care medicine1472-0299135May 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.anaesthesiajournal.co.uk/article/PIIS1472029912000926/abstract?rss=yesContents10.1016/S1472-0299(12)00092-6Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5OFCOFChttp://www.anaesthesiajournal.co.uk/article/PIIS147202991200094X/abstract?rss=yesEditorial Board10.1016/S1472-0299(12)00094-XAnaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5iihttp://www.anaesthesiajournal.co.uk/article/PIIS1472029912000318/abstract?rss=yesAbstract: Severe sepsis is a heterogeneous condition affecting multiple organ systems, and is commonly encountered in the hospital setting due to both community and nosocomial infections. The incidence of severe sepsis has increased over the past decades, and mortality remains alarmingly high. Management of the septic patient involves rapid evaluation and prompt initiation of both supportive and specific therapies. Such patients commonly require admission to the intensive care unit (ICU) for invasive monitoring and haemodynamic support. Resuscitation, early initiation of broad-spectrum antimicrobial therapy and source control remain the cornerstones of therapy. Controversy persists about the roles and benefits of early goal-directed therapy (EGDT), corticosteroids and the advantage of albumin over saline as resuscitation fluid. This review summarizes the contemporary evidence regarding diagnostic and treatment strategies of severe sepsis, with emphasis on patients in critical care settings.Treatment of severe sepsisDashiell Gantner, Alistair Nichol10.1016/j.mpaic.2012.02.005Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Intensive care199203http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000355/abstract?rss=yesAbstract: Nosocomial infection in the intensive care unit (ICU) is associated with increased mortality, morbidity and length of stay. It is defined as infection that begins 48 hours after admission to hospital. The commonest types are ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), urinary catheter-related infection and surgical site infection. The common pathogens include Staphylococcus aureus, Pseudomonas aeruginosa, Candida, Escherichia coli and Klebsiella species. Antimicrobial resistance is increasing and has emerged from selective pressure from antibiotic use and transmission via health workers. Prevention of infection is fundamental and can be achieved through good antimicrobial use and infection control, including hand hygiene. Grouped, easy-to-follow best practice activities called ‘care bundles’ have been developed to prevent VAP and CLABSI. Microbiological cultures are central to rapid and accurate diagnosis, which improves outcomes and reduces resistance. The principles of treatment include early antimicrobial therapy (after appropriate specimens are taken) targeted to the local microbes, then de-escalation according to culture and susceptibility results. This article summarizes the pathogenesis, risk factors, microbiology, diagnosis, prevention and treatment of VAP, CLABSI and nosocomial urinary tract infection in the adult ICU.Nosocomial infections in the intensive care unitSuman S. Majumdar, Alexander A. Padiglione10.1016/j.mpaic.2012.02.009Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Intensive care204208http://www.anaesthesiajournal.co.uk/article/PIIS147202991200032X/abstract?rss=yesAbstract: Anaemia is common in the intensive care unit (ICU) patient and is usually due to the interplay between many different factors. Although often this can be safely managed conservatively, red cell transfusion is commonly required. Patients who refuse blood products and patients with critical bleeding pose a particular management challenge.Coagulopathy is also frequently encountered in ICU. It is critical to evaluate the causes and bleeding risk in such patients, as this will determine the subsequent management. In the stable patient it is often not necessary to correct the coagulopathy.Heparin resistance is failure to reach therapeutic targets using heparin as measured by commonly used laboratory tests. It is influenced by a number of factors relating to the nature of heparin and its mode of action and may result in failure to achieve intended clinical outcomes.Heparin-induced thrombocytopenia (HIT) is an immune-mediated syndrome caused by heparin-dependent antibodies leading to platelet activation and subsequent thrombocytopenia. Awareness and prompt treatment are essential to prevent morbidity and mortality resulting from the development of thrombosis, which can occur in half of patients with HIT.Haematological problems in intensive careMarija Nedeljkovic, Amanda K. Davis10.1016/j.mpaic.2012.02.006Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Intensive care209213http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000331/abstract?rss=yesAbstract: Patients who survive critical illness experience reduced health-related quality of life, impaired physical and cognitive functioning as well as psychological morbidity. These changes may be inter-connected and in part may relate to the loss of physical function at the time of critical illness. Rehabilitation of critically ill patients has largely focused on the post-acute and home phases of recovery. However, recent data show that it is safe, feasible and beneficial to engage critically ill patients in rehabilitation activities early on in their illness. Future research should focus on confirming these findings in a wider patient population and on the key role of knowledge translation in implementing these findings.Rehabilitation and critical illnessShannon L. Goddard, Brian H. Cuthbertson10.1016/j.mpaic.2012.02.007Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Intensive care214216http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000306/abstract?rss=yesAbstract: The airway begins to develop from the primitive foregut at 4 weeks' gestation. Congenital anomalies may result when this process is abnormal. The anatomy of the airway at birth is uniquely different from older children and adults with a large tongue, long floppy epiglottis, large occiput, cephalad larynx, and narrow cricoid cartilage. These features affect the technique required for endotracheal intubation and facemask ventilation. A neutral head position and straight bladed laryngoscope are usually used. Neonates are also obligate nasal breathers and simultaneously suckle and breathe. Minute volume is rate-dependent and the highly compliant chest easily displays sternal and intercostal recession during respiratory distress, and early onset of fatigue. From the neonatal period onwards the anatomy gradually begins to resemble that of adults. The cricoid descends caudally, the epiglottis becomes firmer and shorter, and the large occiput recedes. By 8–10 years the airway is anatomically adult in most ways other than absolute size. The ‘sniffing the morning air’ and curved laryngoscope become appropriate for endotracheal intubation. Conventionally, uncuffed endotracheal tubes have been used in children; however high volume-low pressure cuffed tubes are now available, allowing monitoring of the cuff pressure intermittently throughout use.Developmental anatomy of the airwayCorina Lee, Edward Doyle10.1016/j.mpaic.2012.02.004Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Paediatrics217219http://www.anaesthesiajournal.co.uk/article/PIIS147202991200029X/abstract?rss=yesAbstract: Airway obstruction is more common in children than in adults. This is because of subtle anatomical differences in the childhood airway and an increased propensity to infection. Effects of obstruction manifest more quickly in children because of a smaller airway diameter, reduced physiological reserve and easily fatigued respiratory muscles. The anaesthetist may encounter airway obstruction in children both outside and within the operating theatre. Problems can be either anticipated or unexpected. The anaesthetist must be able to recognize risk factors for airway obstruction such as a history of respiratory symptoms, including sleep-disordered breathing, and high-risk groups, such as ex-preterm infants. An understanding of the pathophysiology of airway obstruction can help in the recognition, diagnosis and appropriate management of airway obstruction. The pathophysiology of airway obstruction is intimately linked with the anatomy and mechanics of the upper airway and the tracheobronchial tree. The pathophysiology of airway obstruction is reviewed and this knowledge applied to problems occurring inside and outside the operating theatre, including both anticipated and unexpected problems.Acute and chronic airway obstruction in childrenGary M. Doherty10.1016/j.mpaic.2012.02.003Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Paediatrics220225http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000288/abstract?rss=yesAbstract: It is essential that all anaesthetists have a strategy for managing the predicted difficult paediatric airway. The majority of children who have difficult airways are identifiable preoperatively. The situation where a child is unexpectedly difficult to bag-and-mask ventilate, intubate, or both is rare. Therefore anaesthetists usually have adequate time for thought and preparation with regard to ultimately securing the airway.Inadequate airway assessment can contribute to poor airway outcomes. This article outlines the anatomical and physiological differences present in the child and describes clinical assessment of the paediatric airway. Equipment available for managing the predicted difficult airway in a child is also reviewed. Video laryngoscopy, for example, has become more popular in recent years and may increasingly be incorporated into difficult airway algorithms of the future.Emphasis is placed on planning, preparation and practice: the three Ps of the difficult paediatric airway.Assessment and management of the predicted difficult airway in babies and childrenJamuna Navaratnarajah, Ann E. Black10.1016/j.mpaic.2012.02.002Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Paediatrics226233http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000367/abstract?rss=yesAbstract: This review is an update of anaesthesia for elective ear, nose and throat procedures commonly performed in the paediatric population. Increasingly these often-complex procedures are being undertaken as day cases and so preoperative assessment needs to be tailored accordingly to identify those children requiring closer postoperative monitoring. Assessment of co-morbidities, consequences of the child’s presenting pathology (e.g. obstructive sleep apnoea (OSA)), bleeding risk and the presence of any concurrent upper respiratory tract infections needs to be the focus of the preoperative visit. Day case procedures involve careful patient selection and good communication with families regarding the post-operative phase and potential complications. Adenotonsillectomy is most commonly performed to relieve the symptoms of OSA. The main anaesthetic concerns include co-morbidities (e.g. obesity), analgesia including the potential use of non-opioids like dexmedetomidine, post-operative nausea and vomiting (PONV), risk of postoperative haemorrhage, postoperative respiratory complications and postoperative disposition. Children undergoing middle ear surgery need careful consideration to prevent problems associated with bleeding, hypothermia and PONV, and staff need to be aware of any hearing deficit that the child may have. Use of lasers is common in airway surgery with children often having repeated laser procedures; associated risks include airway fire and injury to the eyes of the patient and theatre staff.Anaesthesia for elective ear, nose and throat surgery in childrenZoë Brown, Simon Whyte10.1016/j.mpaic.2012.02.010Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Paediatrics234239http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000343/abstract?rss=yesAbstract: Consent must be fully informed and freely given by a competent individual. Where the patient is a child, they can give their own consent provided they are competent to do so, otherwise it must be sought from someone with parental responsibility. This article discusses consent in children for both treatment and research.Consent in childrenHugo Wellesley, Ian A. Jenkins10.1016/j.mpaic.2012.02.008Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Paediatrics240242http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000604/abstract?rss=yesAbstract: It is possible to establish and maintain targeted blood and effect-site drug concentrations with reasonable accuracy using a ‘bolus, elimination, transfer’ (BET) infusion regimen. Simulation software that employs pharmacokinetic models can be used to drive infusion pumps or to design manually-controlled BET infusions. Prolonged infusions can result in prolonged recovery times. However the elimination half-lives of infused lipid soluble drugs have little or no relevance to rates of recovery because elimination half-life does not take redistribution from peripheral compartments into account. A better method is to calculate the context-sensitive decrement times (context-sensitive referring to the infusion duration). These are not represented by a single number: they are a continuum of time values that are a function of infusion duration and can be represented by a graph. Considering that decrement times depend on the concentrations achieved as well as the dose history, it is often difficult for clinicians to anticipate a patient's time to recovery. Pharmacokinetic simulation software continuously calculates and displays expected recovery times, helping clinicians to ascertain when to reduce or terminate the infusion.Principles of intravenous drug infusionJohan F. Coetzee10.1016/j.mpaic.2012.02.011Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Pharmacology243246http://www.anaesthesiajournal.co.uk/article/PIIS1472029912000987/abstract?rss=yes(pp 226–233) In which of the following conditions does the management of the airway become easier with increasing age?MCQsHenry G.W. Paw, Vijayanand Nadella10.1016/j.mpaic.2012.04.001Anaesthesia & intensive care medicine 13, 5 (2012)2012-05-01Anaesthesia & intensive care medicine2012-05-01135S1472-0299(12)X0005-5Test yourself247247