Pitfalls in anaesthesia for multiply injured patients
1982; Elsevier BV; Volume: 14; Issue: 1 Linguagem: Inglês
10.1016/s0020-1383(82)80017-x
ISSN1879-0267
Autores Tópico(s)Cardiac Arrest and Resuscitation
ResumoIN PROVIDING anaesthesia for the multiply injured patient the anaesthetist may find that he is faced with a variety of choices. Examples: Should he use positive end expiratory pressure (PEEP) ventilation, in patients with severe pulmonary contusion, increased intracranial pressure and haemorrhagic shock? Should he resuscitate these patients with crystalloids or with colloids? What measures should he take to prevent aspiration of gastric content? Such dilemmas may exist and depend on the type and combination of the injuries. Many injured patients may also have major systemic diseases which can influence the course of anaesthesia and should be recognized before deciding the best types of treatment. Quite often pre-existing conditions are unrecognized and then the choice of methods must rest on the nature of the injuries and the experience and skill of the anaesthetist. As most multiply injured patients need an operation immediately after admission, there can be no stabilization period before anaesthesia. This may mean that medical treatment has to begin during anaesthesia and decisions must be taken during this time about the further course of treatment. If anuria is present on admission, then stimulation of urine production should be undertaken during anaesthesia to prevent the development of renal impairment or failure, Antibiotic treatment often needs to be started at this time. The prognosis in multiply injured patients is often uncertain and victims with shock and acute respiratory failure after chest injury have a high mortality and morbidity rate if proper treatment is not carried out (Wilson et al., 1977). It should also be realized that the mortality due to anaesthesia is doubled or even trebled in emergency operations compared with elective cases (Vacanti et al., 1970: Feigal and Blaisdell, 1979). Therefore, for example, with pre-existing cardiovascular disease we must carefully consider whether delay is possible to allow for adequate preparation of the patient for the stress of the operation and the anaesthetic. On the other hand, valuable time should not be lost by looking for irrelevant information. In view of possible underlying medical diseases, the absence of a history and the various choices available and the need to make quick decisions, these patients should be anaesthetized by experienced consultants and not by junior doctors. This is true for all the other people involved in treating multiply injured patients, as has recently been stressed by West et al. (1979). I would now like to discuss some of the pitfalls that can confront even the experienced anaesthetist when dealing with these cases.
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