如何写好麻醉和围手术期医学的病例报告

作者：张   丽 徐医麻醉2022级专硕

审校：赵林林 徐医附院麻醉科

How to write a case report in anaesthesia and perioperative medicine

如何写好麻醉和围手术期医学的病例报告

Case reports present the authors’perspective on a particular clinical episode, typically involving an innovation, error, complication or challenging case . Whilst the learning that arises from case reports is situated in the circumstances of that case, there are often educational messages that can be applied in similar situations . This makes case reports particularly important in alerting the peri-operative healthcare community to potential threats to patient safety and descriptions of new phenomena. For example, case reports had an invaluable role in the COVID-19 pandemic by allowing colleagues to share learning about the management of a hitherto unknown disease . Furthermore, case reports provide an opportunity to gain insights into patient and carer experiences, which are seldom reported in detail in other types of research .

    病例报告呈现了作者对特定临床病例的观点，通常是涉及创新、失误、并发症或具有挑战性的病例。虽然从病例报告中获得的知识是基于该病例的特定情况，但通常也具有可以应用于类似情况的教育意义。这使得病例报告在提醒围手术期医疗团队注意对患者安全构成的潜在威胁和对新症状的描述方面尤为重要。例如，病例报告在covid-19大流行中发挥了宝贵作用，使同行们能够分享关于迄今未知疾病管理的知识。此外，病例报告提供了深入了解患者和管理患者经验的机会，这在其他类型的研究中很少被详细报道。

Anaesthesia Reports is a journal of the Association of Anaesthetists, published by Wiley. Launched in 2019, it provides a unique forum for case reports, short case series, multimedia and educational articles relating to anaesthesia, peri-operative medicine, critical care and pain therapy. In this article, we draw on our experience as Editors of Anaesthesia Reports to explain what reviewers and editors seek when considering a case report submission and offer advice about how to ensure the clear communication of two key elements that all case reports should contain: novelty and educational impact.

    《Anaesthesia Reports》是Wiley推出的麻醉医师协会杂志。该论坛于2019年启动，它为病例报告、短篇病例系列、围手术期医学、危重症救治和疼痛治疗相关提供了一个独特的论坛。在这篇文章中，我们利用我们作为《Anaesthesia Reports》编辑的经验来解释审稿人和编辑在考虑提交病例报告时寻求的是什么，并提出建议，即如何确保所有病例报告都包含两个明确的关键元素（新颖性和教育意义）。

How to identify an appropriate case

如何确定一个合适的病例

Cases which stimulate discussion, require a unique approach to management or provide a basis for reflection may make a good basis for a published report. Both successes and failures can form a valuable basis for reflection, and it is often useful to share approaches to rare and interesting cases with colleagues.

   能够引起同道讨论、需要特殊的管理方法或能够提供反思基础的病例，是发表报告的良好基础。成功和失败都可以形成有价值的反思基础，养成与同事分享罕见和有趣病例的习惯是非常有用的。

Novelty is an important element of case reports because it engages the reader and allows them to learn from the unique experiences of others. Whilst every case is unique in some sense, authors must articulate why their case is sufficiently different from those already in the literature (or, simply, routine practice) to justify publication; this requires a focused review of similar published cases. Although case reports relating to a new drug or disease are obviously novel, elements of novelty can also arise from the particular circumstances, solutions, combinations of comorbidity or human factors within a case. For example, a recent multimedia report by Ward and Allam discussed the case of a patient who was found to have a `Mallampati class zero´ (epiglottis visible on mouth opening) during airway assessment. Though unusual, this has been reported previously in several papers and so would not, in itself, have justified publication. However, the novelty in this case also related to the successful use of a supraglottic airway device, despite the potential risk of down-folding of the epiglottis, which had not been reported before. This added an educational element to the report about both a potential complication and successful airway management technique .

    新颖性是病例报告的一个重要元素，因为它吸引读者，让他们从他人的独特经验中学习。虽然每个病例在某种意义上都是独特的，但作者必须阐明为什么他们的病例与文献中已有的病例（或者是常规实践）不同，以证明发表的合理性；这需要对已发表的类似病例进行集中审查。一种新药或一种罕见疾病有关的病例报告显然是新颖的，但新颖性也可能来自病例中的特殊情况、解决方案、共患病或人为因素的组合。例如，Ward和Allam最近的一份多媒体报告讨论了一个病例，该患者在气道评估中被发现有“Mallampati 0级”(在张口时可见会厌)。虽然不寻常，但这在之前的几篇论文中已经报道过，因此该病例本身发表是不合理的。然而，该病例的新奇之处还与成功使用声门上气道装置有关，尽管有会厌向下折叠的潜在风险，但这在以前从未被报道过。这为报告增加了一个教育意义：关于潜在并发症和成功气道管理技术。

The educational impact of a case report relates to its potential to influence the practice, or enhance the knowledge, of the reader. Novel topics may be inherently educational simply because they have not been encountered before. However, in some cases, a topic can appear so obscure or specific that its relevance to others is limited. Therefore, authors should always explain how they believe that the experiences reported in their work may impact the practice of others. This usually involves relating the subject of the report to the existing literature and reflecting on the actions taken, including how the experience will change the authors’ future practice and what they would do differently if they encountered the same scenario again.

    病例报告的教育意义与它影响读者临床实践或提高读者知识储备的潜力有关。新颖的话题可能是天生的有教育意义，因为以前没有遇到过。然而，在某些情况下，一个主题可能显得模糊或具体，以至于它与其他主题的相关性有限。因此，作者应该解释他们所认为的，在他们的工作中所报告的经验可能如何影响其他人的临床实践。这通常涉及到将病例报告的主题与现有的文献联系起来，并对所采取的医疗行为进行反思，包括这一经验将如何改变作者未来的实践，以及如果他们再次遇到相同的情况，是否会采取不同的医疗行为。

Images, diagrams and tables may greatly enhance the educational value of a report. Clinical images (e.g. photographs, radiographs, videos or echocardiograms) are a particularly powerful addition because they bring the case to life for the reader and provide an element of description that is difficult to achieve in written prose. Authors should, however, take particular care to maintain patient anonymity and dignity within a clinical image. This includes obscuring the patient’s eyes in any photographs, deleting any patient identifiable data from radiographic images and ensuring that patients have approved any photographic images for publication.

    图像、图表和表格可以大大提高报告的教育价值。临床图像（如照片、x光片、视频或超声心动图)是一个特别有力的补充，因为它们不仅使病例生动可见，还提供了书面难以描述的重要内容。然而，作者应该特别注意在临床图像中保护患者的隐私。这包括在照片中遮挡患者的眼睛，从放射图像中删除任何可识别患者的数据，并确保患者知情同意。

How to maintain high ethical standards

如何保持较高的道德水准

Case reports create a written and published record of an aspect of a patient’s medical journey or condition. As such, obtaining written evidence of informed consent is a cornerstone of all case reports. All manuscripts containing specific patient data must be published with the written consent of the patient, or if the patient is unable to provide informed consent themselves, the written assent of a consultee, parent or legal guardian, as appropriate. This is not only important from an ethical perspective, but also from a legal one. Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian under the UK’s data protection legislation. If the patient is deceased, the Data Protection Act does not apply, but the authors must seek permission from a relative (ideally the next of kin).

    病例报告为患者的治疗过程或病情创建了书面和公开的记录。因此，获得患者知情同意的书面文书是所有病例报告的前提。所有包含特定患者资料的稿件必须在患者书面同意的情况下发表，如果患者自己无法签署知情同意，则必须获得家属或法定监护人的书面同意（视情况而定）。不管从伦理的角度还是从法律的角度看都很重要。根据英国的数据保护立法，任何可识别的在世患者的个人信息的发布都需要患者或监护人的明确同意。如果患者已经去世，数据保护法不适用，但作者必须获得亲属(最好是最近的亲属)的许可。

When obtaining consent for a case report, authors must apply the principles of valid consent: the author must explain what case report publication involves and the patient must have mental capacity (i.e. be able to understand, weigh up and retain the information and communicate their decision). Consent must be granted voluntarily, without coercion or duress. We acknowledge that there are often barriers to obtaining informed consent, particularly in reports relating to critical illness and the peri-operative period; however, authors must ensure that every effort is made to obtain consent from the patient. If the patient does not have capacity to consent then it may be appropriate to obtain the assent of a consultee (e.g. the next of kin). However, if the patient regains capacity, for example, following a period of sedation while critically ill, we recommend that patient consent is obtained subsequently. Authors should ensure that the consent process occurs in the patient’s own language, which may require the use of an interpreter.

    在获得病例报告的同意时，作者必须应用有效同意的原则：作者必须向患者解释病例报告的发表涉及到什么，患者必须具有正常的心智（即能够理解、权衡和保留信息并且能够沟通其决定)。同意必须是自愿的，没有胁迫。我们承认，在获得知情同意方面往往存在障碍，特别是在有关危重疾病和围手术期的报告中；然而，作者必须确保尽可能获得患者的知情同意。如果患者没有知情同意的能力，则可能需要获得家属(近亲)的同意。然而，如果患者恢复了自主能力，例如，在病危时服用了一段时间的镇静剂，我们建议随后获得患者的同意。作者应确保知情同意过程是以患者自己的语言为主，这可能需要使用翻译人员。

How to structure a case report 

如何撰写病例报告

Case reports should be concise, accessible and clearly communicated. They should set the case in context, then provide an appropriate balance between the description of the case and reflection on the key learning points, with the latter being an important opportunity to make the report relevant to readers. As such, we recommend that the introduction be relatively brief, aiming to achieve a focused explanation of why the report is important. The report should strike a balance between detail and brevity, the guiding principle being that the reader should be able to understand what was done and why. More text should be allowed for the discussion, to permit in-depth analysis and reflection on the details of the case. The specific content of each section will depend on the subject of the report, but as a guide we recommend using the items suggested in the Anaesthesia Case Report (ACRE) checklist for cases in the peri-operative setting (Table 1). This is usually more appropriate than general case report checklists such as the Case Report (CARE) guidelines because these focus on making diagnoses, whilst peri-operative case reports tend to focus on overcoming challenges. The title and summary/abstract should be finalised once the rest of the report is written, as they need to represent the circumstances of the case and present core messages accurately and concisely. Titles can be challenging to write; our preference is that they are succinct but with sufficient information about the case to allow a reader to immediately understand what the report is about. We do not recommend enigmatic titles; though they may pique the interest of the casual reader, they are unhelpful to those who are searching for information on a particular subject.

    病例报告应该简明扼要、易于阅读、逻辑思路清晰。作者应该根据上下文内容报告病例，然后对病例进行分析，并对关键的学习要点进行反思，这是使病例报告与读者产生共鸣的重要内容。因此，我们建议引言应相对简短，旨在说明报告的亮点。报告叙述应在细节和简洁性之间取得平衡，目的是让读者能够理解这篇病例报告的必要性。病例叙述应该为最后的讨论留出足够空间，以便对病例的细节进行深入分析和思考。每个部分的具体内容将取决于在围手术期中麻醉病例报告检查表中建议所示（表1）。这通常比一般的病例报告检查清单(如病例报告指南)更合适，因为这些检查清单专注于诊断，而围手术期病例报告往往关注的是克服各种挑战。报告的标题和摘要应在报告的其它部分完成后再确定，因为它们代表病例的大致情况，并准确简洁地呈现出全文核心信息。定标题更具有挑战性；虽然倾向于简洁，但又要包含足够的病例信息，让读者看过标题就能立即理解报告的主要内容。虽然神秘标题可能会激起普通读者的兴趣，但对于那些正在搜索特定主题的信息的人来说是没有帮助的，因此不作为推荐。 

How to maximise value for the reader

如何为读者传递更多价值

Reflection is particularly powerful in cases where things did not go according to plan, such as the account by Davidson et al. of upper airway obstruction due to arteriovenous malformation rupture in a patient with neurofibromatosis, in which an emergency front of neck airway (eFONA) was required following failed intubation of the trachea . In the discussion, the authors reflect on how early examination findings could have prompted a different airway management strategy, such as awake fibreoptic tracheal intubation or awake tracheostomy. They go on to consider how this case might inform training in teamwork, communication and technical skills. Numerous guides for reflective writing are available, but the structure suggested by Gibbs (Fig. 1) provides a useful framework .

    如果病例处理的结果达不到预期，在讨论中的反思尤为有价值。例如，Davidson等人报告的1例神经纤维瘤病患者，因动静脉畸形破裂导致上气道阻塞，在气管插管失败后需要紧急前颈气道(eFONA)。在讨论中，作者反思了早期检查结果本应该可以选择一个不同的气道管理策略，如清醒时纤维气管插管或清醒气管造口术。作者还在报告中讨论了这个病例将如何指导团队合作、沟通和技术技能的培训。关于指导如何写好讨论中的反思有很多种，而Gibbs的建议提供了一个实用的框架(图1)。

Patient perspectives are a vital and under-reported aspect of anaesthesia, peri-operative medicine, critical care and pain management. Case reports offer a unique opportunity for patients to provide feedback in their own words on the care they received. There are two ways to achieve this: patients can act as authors, either alone or in collaboration with the healthcare professionals involved in their care; or the patient can provide some text which can be included in the report as an excerpt. Patient authorship arguably makes the report more powerful because it places the patient perspective at the heart of the manuscript, but patient authors should weigh up the potential benefits of this approach against the possible undesirable impacts of authorship including publicity that the article may attract; loss of confidentiality and requirement to be accountable for the content of the paper. To date, the patient co-authors of papers published in Anaesthesia Reports have been healthcare professionals. However, there is no expectation that patients who are healthcare professionals should be named co-authors as they have the same right to confidentiality as everyone else. Whatever approach is used must be acceptable to the patient, and authors should consider how best to ensure that the patient is able to present an authentic version of their experiences; for example, by taking steps to moderate the hierarchies that exist between healthcare professionals and patients.

    患者视角是麻醉、围手术期医学、重症医学和疼痛管理的一个重要的但未被报道的方面。病例报告为患者提供了一个独特的机会，让他们用自己的话对所接受的治疗提供反馈。有两种方法可以实现这一点：患者可以单独充当作者，也可以与参与其医疗护理的专业人员合作；或者患者可以提供一些文本，作为报告的摘录。患者作为作者可以说使报告更加有说服力，因为患者的观点是文章的核心，但应该权衡这种方法的好处和作者身份可能带来的不良影响，包括文章可能吸引的宣传；失去隐私保密性，并且要求对论文的内容负责。迄今为止，在《Anaesthesia Reports》上发表论文的患者合著者都是医疗专业人员。然而，不建议作为医疗专业人员的患者被命名为共同作者，因为他们与其他人一样拥有隐私权。无论使用何种方法，都必须经过患者的同意，作者应该考虑怎样可以最好地保护患者，并能够呈现出患者的真实感受；例如，通过采取一些举措来缓和医疗专业人员和患者之间存在的隔阂。

Though it is typical for case reports of anaesthesia, perioperative practice, critical care and pain therapy to be written by physicians working in those fields, reports written by healthcare providers of all professional backgrounds provide a vital addition to the literature. Furthermore, these areas of practice are notable for their close ties to other specialties and the involvement of a broad multidisciplinary team. As such, it is often advantageous to work with a diverse authorship group. A case relating to airway management may, for example, be enriched by including insights from anaesthetic assistants and surgeons as well as anaesthesia providers, allowing the reader to appreciate different perspectives on a problem.

    虽然麻醉、围手术期实践、重症医学和疼痛治疗的病例报告通常由在这些领域工作的医生撰写，但与其相关的医护人员可以为撰写的文献提供重要的补充，最终实现共赢。因此，与不同的作者团队一起工作通常是有利的。例如一个与气道管理有关的病例，可以通过麻醉助手、外科医生以及麻醉提供者的见解来丰富，使读者可以从不同的角度进行理解。

Case reports offer a unique opportunity to share a case that has provided a challenge, learning point or novel finding. They afford the authors the privilege to tell a patient’s story for the benefit of continued learning, which in turn may benefit future patients. Case reports should provide both novelty and educational value for the reader, in a concise and accessible format. The incorporation of the patient voice into a case report adds a further dimension to our understanding of the impacts of care. Prior to embarking on the composition of a report, it is very important to obtain the informed consent of the patient in question. With careful attention to these points, authors should be able to write a novel, educational report which reflects the key learning points from an interesting case.

    病例报告为分享具有挑战性、学习点或有新发现的病例提供了一个独特的机会。使作者有机会讲述一个患者的故事，以帮助他们继续学习，这反过来可能会使未来的患者受益。病例报告应以简明易懂的形式，为读者提供新颖性和教育意义。将患者的声音纳入病例报告中，进一步加深了我们对护理效果的理解。在开始撰写报告之前，获得相关患者的知情同意是非常重要的。仔细注意这些要点，作者就应该能够写出一篇新颖性和具有有教育意义的报告，并从有意义的病例中反映出重要的学习要点。