Maternal physiology undergoes many changes during pregnancy. These are largely secondary to the effects of progesterone and oestrogen which are produced predominantly by the ovary in the first 12 weeks of pregnancy and thereafter are produced by the placenta. These changes both enable the fetus and placenta to grow and prepare the mother and baby for
Pain is a universal phenomenon. Psychological factors influence why and how people respond to their pain and their subsequent demands for analgesia. The individual’s past experiences will shape the way that sensations are labelled as distressing or painful. Consequently, this influences how people behave when in pain and the demands they make relating to their perception of how much treatment they feel that they need. This is demonstrated in both acute and chronic pain conditions. To treat the pain without understanding these psychological factors is to misunderstand the multidimensionality of pain. Whether or not there is an identifiable physical cause for the reported pain, psychosocial and behavioural factors will influence the severity and persistence of pain and associated disability. These factors will influence response to treatment and its outcome. Therefore, when treating pain patients, healthcare providers need to take into consideration not only the physical cause of the pain, but also the needs, fears, expectations and coping strategies of the patient, as well as the responses from their family and friends.
Neurological complications may complicate regional anaesthesia. The incidence has been reported as 0–36 per 10 000 blocks after epidural anaesthesia and 35 per 10 000 blocks after spinal anaesthesia. The most common complication is a reversible neuropathy due to direct needle/catheter trauma or intraneural injection of local anaesthetic presenting as a radiculopathy involving a single spinal nerve root. In a prospective study of over 10 000 obstetric epidural anaesthetics, there were problems with insertion in 13% of cases. The only neurological sequelae reported was one case of neuropathy. A retrospective postal survey in the UK reported a total of 56 cases of prolonged neurological sequelae following spinal or combined spinal-epidural anaesthetics, of which 18 could be attributed to the regional procedure, 29 were of uncertain origin and 9 could be attributed to other factors. The incidence of neurological sequelae in this study was estimated as being around 1 in 1000. It is recognised that under-reporting may occur and the situation is complicated in that neurological dysfunction may also occur co-incidentally or in association with the process of childbirth. Indeed, transient neurological dysfunction in the postpartum period occurs in up to 20% of women, although this is only clinically important in 1 in 500. Any neurological complication in the postpartum period (Table 1) requires careful assessment and, in the majority of cases, reassurance and explanation is all that will be needed. Occasionally, urgent investigation and treatment is required in consultation with a neurologist. Post-dural puncture headache and its differential diagnosis has been discussed recently in this journal (see key references) and will not be considered further.
Purpose of review To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy. Recent findings Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery. Summary Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.
Anaesthesia for infants involves challenges which are different from anaesthesia in older subjects. Overall mortality in the post-neonatal age group (1–12 months) is increased compared with the preschool child. The most common cause of death is congenital abnormality, followed by sudden infant death syndrome (the rate of which is decreasing in the UK in relation to change in sleeping position) and infection. There is also evidence that perioperative morbidity and mortality is greater in the infant compared with the older child. The causes for this are multiple and include the severity of any congenital abnormality together with anatomical, physiological and pathophysiological differences (the latter including the effects of prematurity). An understanding of these differences coupled with a knowledge of altered drug handling may reduce avoidable factors. General considerations
by John Langdon Down, an English physician. He gave the condition the name ‘mongolism’, as he noted the similarities in physical characteristics he saw in institutionalised patients to those of the Mongolian race. Since the early 1960s, the syndrome has taken his name in recognition of this first description. In 1959, the link to a trisomy of chromosome 21 was identified by Lejeune. Subsequently, it has been established that 95% of people with DS have trisomy 21, the remainder are associated with a chromosomal translocation (4%) or mosaic trisomy 21 (1%). The syndrome is the most common chromosomal disorder, occurring in approximately 1 in 700 live births. There is a well-recognised exponential increase in incidence with maternal age (1 in 1400 at 25 years old, 1 in 46 at 45 years old). Fifty years ago, the life expectancy of men and women with DS was 9 years of age, 53% dying in the first year of life. Today, 1-year survival is 90% or more and 45% survive to 60 years old. This increase is predominantly due to improvement in surgical techniques and more aggressive treatment of life-threatening anomalies. With increasing surgical interventions and life expectancy, it is likely that anaesthetists will encounter patients with DS more frequently. DS is a condition that affects many of the organ systems. In this review, we shall consider the congenital defects and pathological conditions which are associated with DS with special reference to anaesthetic implications.
British Journal of Anaesthesia | CEPD Reviews | Volume 8 Number 5 2003 © The Board of Management and Trustees of the British Journal of Anaesthesia 2003 143 Key points The principle of the laser was first described by Albert Einstein. As lasers can cause serious injury to patients, anaesthetists and other theatre staff need to be aware of the basic principles of laser safety. Fires in the airway can be started by lasers, despite the use of appropriate equipment. Lasers are potentially dangerous and evidence for their benefit needs to be evaluated in randomised prospective clinical trials.
When brainstem death was formally defined by the Conference of Medical Royal Colleges and their Faculties in the UK in 1976, a concept, as well as a description of a pathological process, was introduced into medical practice. This article describes core anatomy, pathophysiology of brain injury, the process of testing within the current guidelines and briefly explores the ethical and legal issues inherent in the concept.
Acute Inflammatory polyneuropathies are an important group of neuromuscular disorders and are referred to collectively as Guillain-Barre syndrome (GBS). Our knowledge regarding pathogenesis, diagnosis and management continues to expand, resulting in improved opportunities for identification and treatment. These autoimmune processes cause neuropathy by affecting various structures (myelin or axons), at different locations (nerve root, nerve cell bodies or peripheral nerve) with a variety of patterns. Most clinical neurologists will be involved in the management of patients with these disorders, and there are now a variety of reasonable therapies available for acquired demyelinating neuropathies. In this report, we review the distinctive clinical, laboratory and electro-diagnostic features that aid in their diagnosis, with emphasis on clinical characteristics that are of paramount importance in diagnosing specific conditions and determining the most appropriate therapies, and helpful in determining long-term prognosis.
38 Pre-eclampsia causes increased mortality and morbidity in both mother and fetus. Worldwide, the incidence of maternal death directly related to pregnancy varies widely (6–686 per 100,000 live births) but the consistent feature is that pre-eclampsia is the first or second commonest cause of such death in most countries, and responsible for up to 50% of deaths directly due to pregnancy and its complications.
This chapter contains section titled: Introduction Innate immunity Acquired immunity Lymphoid tissue Transplantation immunology Cancer immunology HIV and AIDS Sepsis, SIRS and multiorgan failure References Further reading
Electrical supply In the UK, mains electricity is supplied as an alternating current, which oscillates at a frequency of 50 Hz. It travels from the substation to its destination in two conductors – the live and the neutral wire. The live wire is at a potential of 240 V, whilst the neutral wire is connected to the earth at the substation and is thus kept at approximately the same potential as earth. These are analogous to the positive and negative wires used with direct current. If a connection is made between the live wire and earth, electricity will flow through that connection to earth. The problems arise when this connection is a patient or member of staff.
Trauma accounts for more than 9000 deaths per annum in the UK. One-third are due to road traffic accidents and chest injuries are responsible for one in four of these deaths. They also play a significant part in 25% of other trauma deaths. Patients admitted with chest injuries often have associated multiple injuries. It is usual for many specialities to share the care of the multi-injured patient. Therefore, good communication is essential. Rapid access to tertiary care surgical services (e.g. cardiothoracic and neurosurgery) are required and access to critical care physicians may improve outcome. Many patients with chest injuries die after admission to hospital and up to one-third of these may be preventable. In 1992, the major trauma outcome study report found that outcome from blunt trauma varied between hospitals in the UK and was worse than that in the US. In 2002, a joint report from The Royal College of Surgeons of England and the British Orthopaedic Association produced recommendations aimed at improving outcome from severe trauma. Recommendations included establishing a national trauma research network, geographically-based trauma systems and the auditing of standards. This document recognised that many patients with chest injuries will be treated by non-cardiothoracic specialists. The occult nature of underlying injuries and difficulties in clinical examination may lead to under-diagnosis of potentially lifethreatening injuries. Further recommendations included investigations targeted to the mode of injury, early specialist intervention and repeated clinical and radiological investigations.
The first surgical choledochoscope was introduced in 1965. Murphy subsequently used this instrument to perform the first ever fibre-optic intubation in 1967. The fibre-optic bronchoscope has now become an essential anaesthetic instrument. Awake intubation of the airway can be achieved safely with a variety of techniques using topical analgesia, regional nerve blockade, with or without sedation. Both oral or nasal routes can be used to achieve fibre-optic-assisted intubation.
