Ian Nesbitt

This article will briefly discuss pandemic planning and its relevance to surgeons. It will cover principally the UK response to the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), although it will also compare and contrast other diseases and reference more general principles of major incident planning. Areas that individual surgeons and departments can, and should, influence are discussed.

David Nicholson apparently has said that NHS staff who disagree with the changes to healthcare outlined in this government’s white paper should leave the service.1 Presumably this is the same David Nicholson who, in June this year, reportedly launched a scathing attack on the white paper’s plans for …

Two case histories of pregnant women with Guillain Barré syndrome (acute demyelinating polyradiculoneuritis) are reported. The first required anaesthesia during the second trimester for a minor surgical procedure. The second woman was admitted to the Intensive Care Unit in the first trimester and was ventilated for 18 weeks. Both babies were carried to term and delivered by Caesarean section. A review of the management of Guillain Barré syndrome in pregnancy discusses anaesthetic management, intensive care and the use of plasmapheresis and γ‐globulins. The care of pregnant women recovered from Guillain Barré syndrome is also discussed.

We present a case of a UK soldier suffering multiple injuries in Afghanistan including a lacerated liver, complicated by acute anuric renal failure. His condition was stabilised prior to transfer to the UK using continuous venovenous haemofiltration. This is the first deployed use of renal replacement therapy by UK forces for several decades, and raises questions regarding the provision of this high level capability in the deployed setting.

Noncardiogenic pulmonary edema in liver transplant recipients is usually secondary to TRALI (transfusion related acute lung injury) or liver ischemic-reperfusion injury. If persistent, the resultant hypoxemia is associated with increased ventilator days, prolonged length of stay (intensive care and hospital) and increased 28-day mortality. Ventilation strategies for the management of hypoxemia in acute lung injury include moderate to high levels of PEEP (positive and expiratory pressure) and prone ventilation (PV). Such strategies have theoretical adverse effects on graft perfusion. Evidence does however exist to demonstrate that maintenance of cardiac output and correct positioning of the prone patient to allow abdominal excursion can negate the deleterious effects of PEEP and PV. A liver transplant recipient became profoundly hypoxemic on our intensive care unit following the onset of noncardiogenic pulmonary edema. A risk-benefit assessment performed at the time deemed that the potential adverse effects of PEEP and PV were outweighed by the life-threatening nature of hypoxemia. The patient's condition improved following prone positioning and application of PEEP (10-15 cm H(2)O). We conclude that such ventilation strategies are appropriate in hypoxemic liver transplant recipients if an appropriate risk-benefit assessment is performed.

group [5, 6]. We have recently conducted a single-centre randomised study of GDT, during which 179 unselected patients having elective colorectal surgery received standard fluid therapy with or without supplementary colloid boluses guided by ODM [7]. Deltex, manufacturers of the CardioQ ODM, provided educational support but remained otherwise independent. Control patients typically received 2.7–4.5 l isotonic crystalloid during the procedure. We found that GDT had no impact on any important clinical endpoints [7]. A unique feature of this trial was that all patients had their aerobic fitness quantified by a pre-operative cardiopulmonary exercise test, such that they could be broadly classified as ‘fit’ or ‘unfit’ in terms of their functional capacity to deliver oxygen to tissues. Roughly, one third were classed as unfit. Some interesting trends became apparent: GDT appeared to hamper the recovery of fit patients, possibly due to fluid overload, such that they took a median of two days longer to reach discharge readiness, whilst there was no such detrimental effect in unfit patients. Moreover, clinical outcomes in our control group were comparable to those of the intervention group in earlier ODM ⁄ GDT trials. Ours is also a small trial, similarly susceptible to confounders: here there was an imbalance in the proportion of colonic versus rectal procedures that favoured the control group. Intra-operative fluid management for major colorectal surgery is a matter of ensuring euvolaemia such that tissue oxygen demand is met by means of adequate organ perfusion throughout the peri-operative period. In our view, and more compellingly in our study, for the majority of our elective patients this can be adequately judged without recourse to expensive additional monitoring.

Cardiovascular optimization via esophageal Doppler can minimize gastrointestinal hypoperfusion, reducing the risk of multiple organ dysfunction and postoperative complications during major surgery. We assessed the effect of esophageal Doppler guided cardiovascular optimization in patients undergoing radical cystectomy. We conducted a prospective, randomized, double-blind controlled trial at a United Kingdom teaching hospital between 2006 and 2009. A total of 66 patients were randomized to a control arm (34) and an intervention arm (32). The control group received standard intraoperative fluids. The intervention group received (additional) Doppler guided fluid. Primary outcomes were markers of gastrointestinal morbidity such as ileus, flatus and bowel opening. Secondary outcomes were postoperative nausea and vomiting, wound infection and operative intravenous fluid volumes (total and hourly). There were significant reductions in the control and intervention arms in the incidence of ileus (18 vs 7, p <0.001), flatus (5.36 vs 3.55 days, p <0.01) and bowel opening (9.79 vs 6.53 days, p = 0.02), respectively. Nausea and vomiting were significantly reduced in the study group at 24 and 48 hours postoperatively (11 vs 3, p…

... I Nesbitt, A Kilner, A Waldram, A Richardson, C Straughan, T Cresswell, L Durham ... Acknowledgements We gratefully acknowledge the teams who identified cases, collected and co-ordinated clinical data: HPA staff, Beverley Alderson, Adam Bell, Kevin Brennan, Steve ...

Noncardiogenic pulmonary edema in liver transplant recipients is usually secondary to TRALI (transfusion related acute lung injury) or liver ischemic-reperfusion injury. If persistent, the resultant hypoxemia is associated with increased ventilator days, prolonged length of stay (intensive care and hospital) and increased 28-day mortality. Ventilation strategies for the management of hypoxemia in acute lung injury include moderate to high levels of PEEP (positive and expiratory pressure) and prone ventilation (PV). Such strategies have theoretical adverse effects on graft perfusion. Evidence does however exist to demonstrate that maintenance of cardiac output and correct positioning of the prone patient to allow abdominal excursion can negate the deleterious effects of PEEP and PV. A liver transplant recipient became profoundly hypoxemic on our intensive care unit following the onset of noncardiogenic pulmonary edema. A risk-benefit assessment performed at the time deemed that the potential adverse effects of PEEP and PV were outweighed by the life-threatening nature of hypoxemia. The patient's condition improved following prone positioning and application of PEEP (10-15 cm H(2)O). We conclude that such ventilation strategies are appropriate in hypoxemic liver transplant recipients if an appropriate risk-benefit assessment is performed.

A patient presented with a phaeochromocytoma crisis during routine anaesthesia for minor ENT surgery. The ensuing cardiac arrest and profound left ventricular failure were successfully treated with an intra-aortic balloon pump until alpha blockade with phenoxybenzamine took effect. The rapid diagnosis of phaeochromocytoma and management of phaeochromocytoma crisis are reviewed.

Within intensive care medicine there is a need to rapidly and safely integrate junior doctors into individual units with effective introductory training. Evolution of such training is influenced by pressures placed on clinicians to maintain standards of care.

Like most doctors, I have seen a great many deaths. Those in intensive care epitomise the undignified nature of death in modern Western society, but one becomes used to, inured to, fully monitored deaths, where coloured lines chart final dysfunction. While working in Samoa, I helped to treat a middle aged patient. Two days after his admission to hospital with back pain, a diagnosis of dissecting thoracic aortic aneurysm was made, and he underwent surgery. The procedure was difficult and prolonged, with a large false lumen, no identifiable re-entry site, and probable carotid artery damage. Within hours of arriving on the intensive care unit, he required an emergency thoracotomy for cardiac …

This may account for the transient bronchospam or at least have contributed to it. Postoperatively, there were no thrombotic or respiratory complications, but graft function was delayed for 2 days and he was temporarily dialysed. He is now home and recovering well after a successful transplant. In summary, the pre-operative assessment of Anderson-Fabry disease should concentrate on end-organ damage to the heart, brain, lungs and kidneys. The older the patient, the more likely it is that they will have a significant degree of organ impairment that will require consideration before major surgery. Investigations should include urinalysis, 12-lead ECG, echocardiography, spirometry and a comprehensive renal assessment. Respiratory function should be carefully assessed in those who continue to smoke and pre-operative treatment with hydrocortisone should perhaps be considered. The need for bronchodilators must be anticipated and avoiding drugs and clinical interventions that are commonly associated with histamine release appears sensible. In elective cases we also advocate having a low threshold for noninvasive cardiac stress tests in those > 30 years of age and relevant symptoms.