Expert Consultant of AKUTNĚ.CZ
Head of Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Faculty of Medicine University of Ostrava, Ostrava-Poruba, Czech Republic
In about last 15 years in western world quickly grew interest in traveling into Asian and South American mountains. Visitors dare to conquer high altitudes, often trying to climb some good accessible and technically not so demanding peaks with height of six or seven thousand meters. Especially by relatively easy ascents the altitude can be gained quickly, and this is very risky for the human body. It is dangerous above all for young and middle-aged well trained people, to whom it is no problem to climb in alpine environments over a thousand meters of altitude in a single day. And this is the biggest stumbling block - the feeling that I can do it, the euphoria of beautiful alpine environment, desire to take advantage of favourable weather, the hope of reaching the dream peak early, drives mountaineers up too quickly. While extraordinary body fitness and good physical form are not synonymous with good ability to rapidly acclimatize for the high altitude. The acclimatization can’t be cheated it can only be gradually completed. The rules for acclimatization in high mountings, including speed, or rather slowness of ascent are well known. However, there are also known too many cases that end badly or even tragically, in their disrespect.
The presented algorithm shows how to proceed, and oppositely how not to proceed when the symptoms of acute mountain sickness and altitude cerebral oedema appears. The topic of algorithm is very interesting and well elaborated. For understanding the topic, with which more and more young and sometimes inexperienced, even if physically fit people come in touch, is the material useful and actual. Congratulations to the young creative team for its composition.
Therapeutic range of intensive care medicine is enormous. Nevertheless, in a certain number of cases, the illness and the overall condition of the patient have progressed so much that, despite all heroic therapeutic measures, the evolution of the patient's health condition leads to leaving the world, and in such patients it is necessary to find the right time to decide, whether it is ethically necessary to continue intensive medicine and hence to treat the medical condition inappropriately or to switch to a palliative treatment and to focus on letting die.
The presented algorithm offers a solution to a typical situation involving a terminally ill oncological patient, from the nurse´s point of view because of his/her irreplaceable role in deciding at the end of patient´s life. They are in long-term and close contact with patients and can sense when all highly sophisticated diagnostics and treatment are in vain, and therefore have the ability to design a whole patient-care team to move from intense to palliative care. In palliative care, nurses play a key role.
Authors have managed to build a didactically convenient algorithm of steps to proceed in such an ethically sensitive situation. It was a good idea to create such an algorithm and I'm glad it will be published at Akutne.cz.
This algorithm discusses another necessary topic – the management of intensive postoperative pain. A very accurate clinical example is chosen - mastectomy is one of the operations after which the post-operative pain can become chronic in a relatively high percentage of cases. Well-managed postoperative analgesia reduces the risk of chronic postmastectomy pain. The algorithm highlights the increasingly available and currently not fully utilized method of patient-controlled intravenous analgesia. It describes the use of the pump, the parameters that need to be set, as well as the choice of opioids that can be used for the PCA, including their dosing. At the same time, in one of its steps the algorithm recommends using gabapentinoids. The use of gabapentinoids is one of the current trends in the way of involving co-analgesics suitable for dealing with neuropathic pain in postoperative analgesia. Their utilisation, among other things, significantly reduces the dose of administered opioids and possibly shortens the period of their administration.