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Expiratory reserve volume is the most sensitive indicator of the effect of obesity on pulmonary function testing. Plasminogen activator inhibitor-1 (PAI-1), which is secreted by  adipocytes  associated with visceral obesity inhibits the fibrinolytic system. PAI-1 decreases fibrinolysis and increases the risk of coronary artery disease. Gastric emptying is delayed in obese patients because of increased abdominal mass that causes antral distension, gastrin release, and a decrease in pH with parietal cell hypersecretion. The magnitude of body mass index does not have much influence on the difficulty of laryngoscopy. Neck circumference has been identified as the single biggest predictor of problematic intubation in morbidly obese patients Preoxygenation in the head-up or sitting position is more effective and provides the longest safe apnea period during induction of anesthesia in obese patients. Positive end-expiratory pressure is the only ventilatory parameter that has...

D. Saal; T. Heidegger; M. Nuebling; R. Germann Br J Anaesth. 2011;107(5):703-709. Abstract Background. 'Continuity of personal care by anaesthetist', as defined by a single anaesthetist providing preoperative evaluation, performing anaesthesia, and delivering a postoperative visit to the patient, has been shown to be a major factor for patient satisfaction with anaesthesia care. This prospective randomized study investigated whether a single postoperative visit increased the patient's perception of 'Continuity of personal care by anaesthetist' and hence satisfaction. Methods. In Group 1, the same anaesthetist who conducted anaesthesia visited the patient on the first postoperative day. In Group 2, a nurse anaesthetist who did not participate in anaesthesia delivery made a postoperative visit to the patient. Patients in Group 3 were not visited. Patients received a previously validated questionnaire after discharge from hospital. Results. The negative patient resp...

Oxygen index (OI) >40 on 2 or more arterial blood gas measurements                         [OI = (MAP x FIO2 x 100) ÷ PaO2] PaO2 <40 mmHg for 4 h in 100% O2 Intractable metabolic acidosis Intractable shock Progressive, intractable pulmonary or cardiac failure Inability to come off cardiopulmonary bypass at operation

The importance of arterial pressure management in patients undergoing anesthesia has been substantiated by the significant relationship between intraoperative hypotension and postoperative neurocognitive impairment. Despite the fact that arterial pressure monitoring is a standard practice, consensus in terms of when and how to treat intraoperative hypotension is still lacking. Among all options, phenylephrine and ephedrine belong to the set of typical sympathomimetic agents routinely chosen to increase arterial pressure.  However, little is known about the impacts of these agents on cerebral oxygenation and the relationship between global and regional haemodynamics. If treating hypotension is an attempt to avoid organ ischaemia and hypoxia, we are actually achieving the opposite result (decreased cerebral oxygenation) by administering phenylephrine, as demonstrated in study ( published in BJA November Issue)  using a quantitative NIRS device and in previous stud...

The superior vena cava (SVC) is easily compressed by tumors arising from the lung, mediastinal structures, or lymph nodes. Malignancies are the most common cause for superior vena cava syndrome (SVCS).  The leading cause of malignancy associated with SVCS is lung cancer, accounting for as many as 60% to 85% of all cases But, as more and more indwelling central venous access devices are used, intrinsic thrombus is becoming a significant cause for SVCS,accounting for as many as 20% to 40% of all cases. Clinical picture SVCS causes edema in the upper body, particularly in the head and neck . This edema may be significant enough to compromise the lumen of the larynx, causing dyspnea and stridor, and compromise of the pharyngeal lumen, causing dysphagia. The most concerning symptoms are neurologic, such as headaches, confusion, or even coma, suggesting cerebral ischemia. Brain stem herniation and death can potentially occur. However, the usual course of SVCS is that collaterals e...

Transfer of drugs from mother to fetus takes place at the level of the placenta mainly by diffusion. Thus, keeping maternal blood levels of drugs as low as possible is a major strategy for decreasing the amount of drug that reaches the fetus.  In addition, since 75% of the blood in the umbilical vein travels to the liver, a large portion of drug can be metabolized before reaching vital fetal organs.  Drug in the unbilical vein that travels via the ductus venosus to access the inferior vena cava will be diluted with blood from the lower extremities (which has no drug) and this further reduces concentration of drugs inthe fetal blood. Two things work against this "safety feature": (1) fetal acidosis during times of distress causes increased perfusion of the heart and brain and thus increases delivery of drug to these important organs. (2) Fetal pH is lower than maternal pH and results in basic drugs (such as local anesthestics) becoming more ionized when they rea...

Helium is the second most abundant element in the universe (that’s cool)! It is an inert gas that is odorless and tasteless. It has a lower molecular weight and is less dense than Oxygen. It has been used in medicine since the 1930’s.It is used as integral part of HELIOX and for  inflation of Intra aortic Ballon  Pumps(IABs)..   In Heliox : Heliox is a mixture of oxygen and Helium resulting in a gas less dense than air (essentially Helium replaces Nitrogen in the air). In conditions where there is increased airway resistance (asthma, croup, upper airway masses, etc) there is turbulent airflow, which increases the work of breathing. Heliox can reduce airway resistance by increasing laminar airflow and decrease work of breathing.      It is generally administered in mixtures of 70:30 or 80:20 (Helium:Oxygen).   Potential Benefits:   Better lung mechanics Improved delivery of albuterol or other nebulized medications Few known sid...

Straight or curved? There are a few degrees lesser extension at C1/2 with a straight blade (LeGrande et al) than curved blade . It is unlikely that this difference is clinically meaningful. What about glidoscope? It seems intuitive that having a video-assisted device that allows one to "look around the corner" would reduce motion. However  the existing data do not always support this Turkstra et al and Robitaille et al failed to show meaningful differences in Cspine motion between intubations performed with Mac3 blades vs. a Glidescope. The Bullard and WuScopes may be better (Watts et al). Is a fiberoptic intubation really "better"? yes - when it can be done smoothly without coughing, gagging or bucking! Several studies haveshown nearly zero Cspine motion with FOB (e.g. Brimacombe et al) - but all bets are off when things don't go smoothly.An option is asleep FOB if you are good with a scope and are certain about your ability to mask ventilate (but rem...

The phenomenon of early post-operative fever (EPOF), generally accepted as fever within the first 48 h of surgery, is still being taught by many as related to ‘just a bit of pulmonary atelectasis. This is an outdated and non-evidencebased view. In observational studies, it has been shown that there is no association between pulmonary atelectasis and Early post operative fever ( EPOF )after abdominal or cardiac surgery. Reducing pulmonary atelectasis volume to less than half the size that seen in controls with regular deep breathing exercises during the first post-operative days does not affect the incidence of magnitude of Post Operative Fever (POF). Surgery is followed by an acute-phase response, including immune and hypothalamo-pituitary-adrenal axis activation and increase in the plasma  levels of IL6. The systemic levels of IL-6 after abdominal, thoracic, vascular and maxillofacial surgery correlates significantly with postoperative body temperature increase. Likew...

T he intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation? A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood: Hemoglobin / hematocrit - good correlation White blood cell count - no correlation Platelet count - no correlation Sodium - no correlation but within 5% of IV value Potassium - no correlation Choloride - good correlation Serum CO2 - no correlation Calcium - no correlation but within 10% of IV value Glucose - good correlation BUN / Creatinine - good correlation Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not ava...

This is a kind of Practice changing piece of data in the management of acute Pancreatitis. Here is the summary of updated literature, and it covers the recent updated in the three pillars of acute pancreatitis management 1-feeding..the question is to feed or not? 2-Antibiotics..the question is to give or not? 3-Surgery..the question to do or not? Here are the answers Regarding Feeding , the answer is "FEED ", Cochrane review in 2010   reached the conclusion – feed patients. In fact fasting has not been shown to help and probably increases the length of admission.  it is always taught that  feeding can increase enzyme production and cause “auto-digestion” – but according to the recent evidenc e it just aren’t so – they get better quicker and don’t suffer worse inflammation / mortality etc.  And if you have a nasogastric tube in – then that is fine – it does not need to be a nasojejunal tube to avoid the dreaded enzymes. Now the second Question...

Some of the atypical antipsychotic agents – quetiapine (Seroquel), onlanzapine (Zyprexa), clozapine (Xlozaril) — have significant anticholinergic properties.The  Am J Emerg Med in  2011 July 28 issue,reported three patients with quetiapine overdose and altered mental status who improved after being treated with the carbamate physostigmine , a cholinergic agent sometimes used to reverse anticholinergic toxicity. The authors stress that since the duration of physostigmine’s effect is only 30 to 90 minutes (far shorter than the duration of quetiapine), patients should be observed carefully and not have their level of care downgraded until at least 4 hours after the last dose  of physostigmine. They conclude that physicians should be aware of [the] association” between quetiapine overdose and improvement in GCS following physostigmine administration.

The Osborn wave 1 (J wave)  usually appears in hypothermia, disappears after normalization of the body temperature, and is usually evident in the inferolateral leads. Although Osborn waves are a marker of hypothermia, they also occur in nonhypothermic conditions. Brainstem death is a precursor of the J wave, and this is explained by impaired thermoregulatory ability resulting from hypothalamic dysfunction and subsequent hypoth   Classic findings in hypothermia include J waves, sinus bradycardia, prolongation of the PR interval, widening of the QRS complex, and prolongation of the QT interval . The lower the core body temperature, the higher the amplitude of the J wave. As hypothermia becomes more profound, the J wave becomes evident in all leads, not only the inferolateral leads. 1 .     Osborn , Experimental hypothermia; respiratory and blood pH changes in relation to cardiac function. Am J Physiol 1953; 175:389–398.  

Recent literature indicates that many patients with a true hypertensive emergency are mismanaged. Patients with a hypertensive emergency should have an arterial line placed and receive a continuous infusion of a short-acting, titratable medication to reduce blood pressure.  Avoid oral, sublingual, and intermittent IV bolus administration of antihypertensives .  Recall that most patients with a hypertensive emergency are volume depleted.  Providing IV fluids can help to prevent marked drops blood pressure when you start an IV antihypertensive medication. Avoid diuretics (due to volume depletion) and hydralazine .  Hydralazine can cause precipitous drops in blood pressure and is felt by many to have no role in the treatment of hypertensive emergencies. Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care 2011; 17:569-80 .

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...

It is well Known that lidociane alleviate propofol injection pain.But  many questions still un answered, What is the adequate dose? The proper timing ? A review of the published studies suggested that injecting lidocaine with a proximal tourniquet provided the highest efficacy. The authors recommended that “IV lidocaine (0.5 mg/kg) should be given with a rubber tourniquet on the forearm, 30 to 120 seconds before the injection of propofol.”  This method was superior to mixing lidocaine with propofol, which itself was superior to giving lidocaine without a tourniquet prior to injecting the propofol . Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90:963–969

First click on this link to see a video on the effect of blood transfusion on Microcirculation                                                                                                                            Press Here  One of the characteristic alterations in stored RBC is a change in shape from a normal biconcave to a spindly cell (echinocyte).(1) This results in lower surface ...