Anaesthesia and intensive care
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Anaesth Intensive Care · Jan 2024
ReviewAirway management of lingual tonsillar hypertrophy: A narrative review.
Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. ⋯ Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.
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Anaesth Intensive Care · Jan 2024
Case ReportsMetabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report.
A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.
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Anaesth Intensive Care · Jan 2024
Randomized Controlled TrialInflammation risk before cardiac surgery and the treatment effect of intraoperative dexamethasone.
Patients who exhibit high systemic inflammation after cardiac surgery may benefit most from pre-emptive anti-inflammatory treatments. In this secondary analysis (n = 813) of the randomised, double-blind Intraoperative High-Dose Dexamethasone for Cardiac Surgery trial, we set out to develop an inflammation risk prediction model and assess whether patients at higher risk benefit from a single intraoperative dose of dexamethasone (1 mg/kg). Inflammation risk before surgery was quantified from a linear regression model developed in the placebo arm, relating preoperatively available covariates to peak postoperative C-reactive protein. ⋯ No treatment-effect heterogeneity was detected for the main clinical outcome (P = 0.167 for interaction). Overall, risk predictions from a model of inflammation after cardiac surgery were associated with the degree of peak postoperative C-reactive protein reduction derived from dexamethasone treatment. Future work should explore the impact of this phenomenon on clinical outcomes in larger surgical populations.
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Anaesth Intensive Care · Jan 2024
Risk factors for mortality in severe COVID-19: Exploring the interplay of immunomodulatory therapy and coinfection.
Patients with severe clinical manifestations of coronavirus disease 2019 (COVID-19) present particular diagnostic and management challenges to critical care physicians, including identifying and responding to concurrent bacterial and fungal coinfections. This study evaluates risk factors for in-hospital mortality in patients admitted to the intensive care unit with severe COVID-19 during circulation of the B.1.617.2 (Delta) variant, including the impact of immunomodulators and bacterial and/or fungal coinfection. This retrospective cohort study enrolled patients with severe COVID-19. ⋯ However, in patients receiving immunomodulators, coinfection carried a significantly higher mortality risk (63.0%) compared with those without coinfection (15.4%; P = 0.038). Mortality from severe COVID-19 is significantly higher in older patients and those with elevated body mass index and requiring mechanical ventilation. Immunomodulatory therapy necessitates vigilance towards evolving coinfection in the intensive care setting.