Anaesthesia & intensive care medicine - Current Issue

Major trauma remains a significant cause of mortality and morbidity, with a profound impact on both society and the individual. The last two decades have seen important changes in the structure of trauma care across the UK. The rollout of major trauma networks and multidisciplinary working has improved care to this cohort. In-hospital management of the trauma patient begins with the trauma team, comprised of different roles, specialities, skills, and experience. The cohesion of this team under the coordination of a trauma team leader is essential for effective management.

Acute pain is prevalent yet frequently undertreated in pre-hospital care. The pre-hospital setting is a dynamic environment, and achieving adequate analgesia is crucial to allow comprehensive assessment, extrication and transport of patients to hospital in a timely and humane manner. Patients may be cared for by a variety of providers throughout their clinical journey, which will influence the analgesia that is provided. Assessment of pain is crucial to its management, and this review summarizes the best practices, and common pitfalls, to pain assessment in pre-hospital care.

Major injury provokes an immediate neuroendocrine, inflammatory and metabolic response. Early sympathetic activation, cortisol release and renin–angiotensin–aldosterone activity preserve perfusion but drive tachycardia, vasoconstriction, hyperglycaemia and early catabolism. Endothelial injury, acidosis, hypothermia and low ionized calcium contribute to trauma-induced coagulopathy and the lethal diamond. These processes inform modern resuscitation, which prioritizes rapid haemorrhage control, balanced resuscitation, permissive hypotension when appropriate and prevention of secondary physiological insults.

Management of the patient with rib fractures

Shock is defined as a failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. Haemorrhagic shock is most commonly associated with trauma. Haemorrhage is a leading cause of preventable death in trauma and over the past two decades there has been an increasing understanding of the pathophysiological processes that occur in major haemorrhage associated with trauma. This has been fundamental to the current approach to management of traumatic shock, known as damage-control resuscitation (DCR).

Non-operating room anaesthesia (NORA) refers to the administration of anaesthesia outside of the traditional operating room environment. This may include procedures performed in the radiology department, interventional cardiology suites, or endoscopy units. With the increasing demand for minimally invasive procedures, the requirement to provide anaesthesia outside the theatre environment is becoming more common. Non-operating room anaesthesia provides a unique set of challenges including airway management, monitoring, procedural access, patient positioning, temperature management, delivery of anaesthesia and management of complications.

Regional anaesthesia (RA) is a core competency across all stages of training in the 2021 Royal College of Anaesthetists (RCOA) curriculum. Anaesthetists must understand RA-related complications to ensure informed consent and safe patient care. Complications are categorized as related to either central neuraxial blockade, peripheral nerve blockade or both. Advances in ultrasound technology, needle visibility, simulation training and structured courses have enhanced RA education. National safety initiatives aim to reduce risk and harm.

This article explores the role of special senses in critical care, emphasizing their importance in patient assessment and recovery. Special senses, including vision, hearing, balance, smell, and taste, are mediated by complex sensory organs located in the head and lack of normal sensory input in critically ill patients can lead to delirium, and increase in morbidity and mortality. The article also emphasizes the importance of a comprehensive understanding of the special senses, which can prevent many serious complications related to critical illnesses and potentially aid in accelerated recovery, ultimately improving patient outcomes.

Peripheral nerve catheters (PNCs) or perineural catheters are used synonymously to describe placing a catheter in close proximity to nerve plexuses or individual nerves for the provision of continuous pain relief. The indications of PNCs extend beyond upper and lower extremity orthopaedic surgery to perioperative analgesia in patients undergoing a broad range of surgical procedures (e.g. abdominal, vascular, thoracic, breast and trauma surgeries). PNC use can facilitate early mobilization after surgery by providing high-quality analgesia that in turn leads to reduced opioid consumption and associated opioid-related side effects.

Intravenous regional anaesthesia, or Bier’s block, is a useful and safe technique for anaesthetizing distal limbs for short surgical procedures. It is most commonly used for reduction of forearm fractures within the emergency department and can be a useful method of providing anaesthesia in patients who may be unsuitable for a general anaesthetic, or when skills or equipment for other forms of regional anaesthesia are unavailable. When performed as recommended it has a proven safety record.

Regional anaesthesia plays a central role in lower limb surgery, offering analgesic benefits, reduced opioid requirements and enhanced recovery. Femoral, adductor canal and popliteal sciatic lower limb blocks are considered ‘Plan A’ blocks and thus form part of a core set of reliable, reproducible techniques which are widely applicable to a variety of clinical situations. ‘Plan B’ options such as ankle blocks can offer more advanced flexible alternatives tailored to specific surgical or patient requirements.

Upper limb regional anaesthesia is a key skill to be mastered in anaesthetic training, offering patients improved postoperative analgesia and potentially a lower-risk alternative to general anaesthesia.With the advent of ultrasound imaging as the gold standard in regional anaesthetic practice, upper limb blocks are now more reliable and accessible than ever before. This article focuses on the anatomical principles of four key brachial plexus blocks as well as practical tips to facilitate clinical practice.

Variation in response to drugs used in anaesthesia is seen between individuals and it is well established that patients' genetics are a major influence. Our understanding of the role differences in the genome play, especially by identifying genetic polymorphisms of interest, is improving. This may lead to availability of precision anaesthesia, where drug choices and dosages are tailored to individuals’ genetic makeup. Furthermore analysis of the downstream products of gene transcription, in particular of proteins and metabolic products, may allow further treatment personalization.

Complications of regional anaesthesia

Insertion of a chest drain for pneumothorax either through open or Seldinger's technique is commonly performed. Clinicians must develop a clear understanding of the indications, anatomical landmarks, and procedural steps to achieve successful patient outcomes. This article will focus on the technical aspects of chest drain insertion.

Local anaesthetics are widely used in the provision of local/regional anaesthesia and the management of acute and chronic pain. Their mechanism of action temporarily inhibits voltage-gated sodium channels in neuronal plasma membranes. Local anaesthetic systemic toxicity (LAST) is a serious yet largely preventable complication that can occur by any of the multiple routes of administration. LAST pre-dominantly affects the central nervous and cardiovascular systems. Awareness of LAST and vigilance during administration of local anaesthetics may help in early recognition and successful management of the toxicity.

Electrolyte disorders are commonplace in the critically ill patient. Abnormalities may provide clues to the diagnosis, severity, and even prognosis of illnesses. Abnormal serum electrolytes can be a marker of total body electrolyte deficit or excess, or movement between compartments. Despite the morbidity and mortality associated with electrolyte disorders in critically ill patients, the evidence to guide management is limited. This article provides a guide to the aetiology, clinical features, and management of major electrolyte disorders in the patients in the intensive care unit.

The recognition of cardiogenic shock in the setting of myocardial ischaemia has important prognostic and therapeutic implications. Resuscitative efforts should focus on stabilizing circulatory and respiratory function, with early restoration of coronary blood flow to avoid multi-organ dysfunction and death. The associated mortality rate remains approximately 40–50%, and few therapeutic strategies have proven to reduce short- and long-term morbidity and mortality to date. This article highlights several key strategies in the management of ischaemic cardiogenic shock, including the use of early echocardiography to confirm diagnosis, and culprit-only lesion strategy of early revascularization.