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Arterial blood gas ( ABG ) analysis is often used in to evaluate pulmonary function in critically ill ED patients. In recent years, venous blood gas ( VBG ) analysis has replaced ABG analysis for assessing acid-base status (pH, HCO 3 - ) in conditions such as DKA . Some key points about the VBG for assessing pulmonary function: VBG does not replace an ABG in determining the exact P a O 2 The agreement between the VBG and ABG PCO 2 is often poor and unpredictable There is emerging literature on the use of VBG PCO 2 as a screen for hypercarbia but more data is needed Bottom line: With the possible exception of screening for hypercarbia , VBG has limited utility in the assessment of pulmonary function. Kelly AM. Can venous blood gas analysis replace arterial in emergency medical care? Emerg Med Australasia 2010;22:493-498

Cardiovascular: - I nitial parasympathetic discharge : prominent during the first ECT treatment, bradycardia , asystole , premature atrial/ventricular contractions. Hypotentsion - Sympathetic discharge follows : tachycardia, hypertension, PVCs, rarely VT. Usually tachycardia is self limited, peaking at 2 minutes -EKG changes: ST-segment depression and T-wave inversion Central Nervous System: -headache, short-term memory loss, confusion, agitation, increased blood flow and CMR, elevated intraocular pressure Neuroendocrine: -increased stress hormones: ACTH, cortisol, vasopressin, prolactin, GH, epinephrine and NE -improvement in NIDDM and hyperglycemia with IDDM Gastrointestinal tract: -elevated intragastric pressure

The dicision whether to proceed with surgery in any child with URTI requires careful risk/benefit analysis on an individual basis and is summarized in the table below. Schedule Cancel Clear runny nose Child < 1 yr Dry cough Purulent nasal discharge Minor surgery Productive cough Wheezing/crepitations on auscultation Systemic features of being unwell, i.e. fever>38, malaise, headache, feeding problems Parental confirmation of child being unwell Also consider patient co-morbidities, type or urgency of surgery, and experience of anaesthetist.

Temperature mangement Therapeutic hypothermia has shown great improvement in the cardiac arrest victims, however for the injured brain: “There is no evidence that hypothermia is beneficial in the treatment of head injury”. Therapeutic hypothermia in the injured brain has resulted in more cases of coagulopathy, pneumonia and sepsis. Bart’s recommend’s we should focus on “therapeutic normothermia” for these patient’s we know cooling is bad, but also fevers and hyperthermia is also detrimental as well. We know fever increases cerebral metabolic rate and oxygen consumption with associated poor outcomes, however there is currently no good outcome studies to support this. Take home point: fevers can develop quickly (yes even while the patient is still in ED), so monitor closely and treat aggressively. Blood pressure Patients with a severe brain injury often present with an abnormal blood pressure. Hypotens...

Prognostic factors in out-hospital arrest 1. Public vs Workplace 2. Age old vs young 3. CPR by bystander 4. Time to defibrillation: after or before EMS 5. Time of day Midnight vs AM 6. Gasping Prognostic factors in in-hospital arrest 1. Rhythm: VF/VT 2.Time to CPR and defibrillation 3. Hospital location: ward vs ICU, Dialysis 4.Time of day 5.AED use Prognostic factors intra-arrest PETCO2: 10 @ 20 is bad!!! Ultrasonography: Cardiac standstill means failed resuscitation regardless of rhythm or monitor Emergency Medicine Clinics of North America ,issue Feb 2012

This week we will discuss Bart'sTips for TBI,it entails 5 topics: Positioning,cervical collar,Blood Pressure,Blood sugar,and Temperature. Today we discuss the first two items: Patient Position Elevating the head of the bed to 30° — will decrease ICP via displacing the CSF and increasing venous outflow. By elevating the head of the bed to between 30°-45° also decrease the risk of developing ventilator associated pneumonia. However elevating the head of the bed can be difficult in the patient with spinal precautions. Bart also recommends avoiding the trendelenburg position (especially when inserting central lines) as this intervention offer’s little benefit but can greatly increase the ICP. Cervical Collar C-Spine collar aka “The Brain Tourniquet”. Clearing the cervical spine of these patients can often be difficult in the comatosed intubated patient. Removal of the C-spine collar has been showen to decrease ICP by around 2-5 mmHg. If you are unable to remov...

Bilateral Total Knee Arthroplasty: Risk Factors for Major Morbidity and Mortality Anesth Analg 2011 Background : Bilateral total knee arthroplasty (BTKA) performed during the same hospitalization carries increased risk for morbidity and mortality compared with the unilateral approach. However, no evidence-based stratifications to identify patients at risk for major morbidity and mortality are available. The objective of the study was to determine the incidence and patient-related risk factors for major morbidity and mortality among patients undergoing BTKA. Methods : Nationwide Inpatient Survey data collected for the years 1998 to 2007 were analyzed and cases of elective BTKA procedures were included. Patient demographics, including comorbidities, were analyzed and frequencies of mortality and major complications were computed. Subsequently, a multivariate analysis was conducted to determine independent risk factors for major morbidity and mortality. Results : Included were 42,003 data...

Vaccination and Anesthesia Vaccines are broadly classified into two categories, that is, live attenuated (BCG, MMR) or inactivated (IPV). Rash and fever are common 7–10 days after MMR, parotitis 3 weeks after MMR, and local reactions and fever within 48 h of DtaP/IPV/Hib. In a survey of anaesthetists by Short and colleagues, 60% of the respondents stated that they would not delay anaesthesia for elective surgery in a recently immunized child, while 40% would postpone for a week for inactive vaccines and 3 weeks for live vaccine. As a conclusion, misinterpretation of vaccine-related adverse events as postoperative complications may be avoided by respecting a minimal delay between immunization and anaesthesia. A delay of 48 hours is needed for children immunized with inactivated vaccine. On the other hand, there is no need to delay anesthetic in a child immunized with live vaccine if the child is well at preoperative assessment. The influence of anaesthesia on various markers of immuni...

The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey Farnaz M. Gazoni, MD, Peter E. Amato, MD, Zahra M. Malik, MD, and Marcel E. Durieux, MD, PhD Anesth Analg 2011 BACKGROUND : Most anesthesiologists will experience at least one perioperative catastrophe over the course of their careers. Very little, however, is known about the emotional impact of these events and their effects on both immediate and long-term ability to provide care. In this study, we examined the incidence of perioperative catastrophes and the impact of these outcomes on American anesthesiologists. METHODS : We sent a self-administered postal survey to 1200 randomly selected members of the American Society of Anesthesiologists. Participants were sent an advance letter, up to 2 copies of the survey, up to 2 reminder postcards, and a small cash incentive. Six hundred fifty-nine physicians (56%) completed the survey. RESULTS : Eighty-four percent of respondents had been involved in a...

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A Review of the Impact of Phenylephrine Administration on Maternal Hemodynamics and Maternal and Neonatal Outcomes in Women Undergoing Cesarean Delivery Ashraf S. Habib, MBBCh, MSc, MHS, FRCA Anesth Analg 2011 Phenylephrine is effective for the management of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery under spinal anesthesia. While ephedrine was previously considered the vasopressor of choice in obstetric patients, phenylephrine is increasingly being used. This is largely due to studies suggesting improved fetal acid base status with the use of phenylephrine as well as the low incidence of hypotension and its related side effects with prophylactic phenylephrine regimens. This review highlights the effects of phenylephrine compared with ephedrine on many important aspects. Here is the conclusion. Both ephedrine and phenylephrine are effective in managing spinal anesthesia-induced hypotension. Phenylephrine may be associated with a lower incidence of...

Bicarb for raised ICP This is a really interesting paper, suggesting a good alternative to hypertonic saline that avoids the problems of hyperchloraemmic metabolic acidosis : Background   Hypertonic saline is routinely used to treat rises in intracranial pressure (ICP) post-traumatic head injury. Repeated doses often cause a hyperchloremic metabolic acidosis. We investigated the efficacy of 8.4% sodium bicarbonate as an alternative method of lowering ICP without generating a metabolic acidosis. Methods  We prospectively studied 10 episodes of unprovoked ICP rise in 7 patients treated with 85 ml of 8.4% sodium bicarbonate in place of our usual 100 ml 5% saline. We measured ICP and mean arterial pressure continuously for 6 h after infusion. Serum pH, pCO2, [Na+], and [Cl−] were measured at baseline, 30 min, 60 min and then hourly for 6 h. Results   At the completion of the infusion (t = 30 min), the mean ICP fell from 28.5 mmHg (±2.62) to 10.33 mmHg (±1.89),P < 0.0...

Carbon dioxide embolism must be distinguished from air embolism, a far more ominous event, as shown in the table below. Carbon dioxide being extremely soluble in the presence of red blood cells, is much less life threatening than an identically sized intravascular bolus of air. Embolism Air CO2 Composition 79% N2, 21% O2 100% CO2 Position Sitting position Any Origin Vein open to air No contact with air Pressure source Hydrostatic insufflator Solubility Negligible Large Effect of N2O Enlarged Not enlarged

The net effect of severe metabolic acidosis: Impaired cardiac contractility Decreased threshold for V-Fib Decreased Hepatic and Renal flow Increased pulmonary vascular  resistance Inability to respond to vasopressors Inhibition of coagulation factors and platelets vascular collapse

Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation. High-flow nasal cannulas ( HFNC ) have been adapted from use in neonates to adults to deliver continuous positive airway pressure ( CPAP ). HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx . Patients tolerate it well and it is less claustrophobic than tight-fitting masks. HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula ) and non-invasive positive pressure ventilation with tight-fitting masks. Check with your respiratory department if these devices are locally available. Kernick , j. What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Cri...

BiPAP now is being used on a wide scale in perioperative medicine  and in critical care units. Today we will discuss the three basic simple rules on How to start it and then adjust your parameters according to the clinical situations? BiPAP – usually start at 8/3 (the first digit is IPAP the second EPAP) and keep IPAP 5 above EPAP. If the patient has hypoxemia EPAP and IPAP should go up in 2 cm H2O increments. Hypercarbia- increase IPAP in 2 cm increments. Easy............... Tomorrow we will discuss the evidence based  use of BiPAP

-Continuous spinal anaesthesia combines the advantages of single-dose spinal anaesthesia, rapid onset and a high degree of success, with those of a continuous technique. -The introduction of micro-catheters invigorated interest in the technique and allowed its expansion to additional populations and surgical procedures. However, multiple cases of cauda equina syndrome associated with micro-catheters and (primarily) hyperbaric lidocaine solution led to withdrawal of micro-catheters from the US market. -In 1992, FDA banned the use of spinal catheters thinner than 24G after 12 cases of cauda equina. 20G cathters are recommended in geriatric patients. -Continuous spinal anesthesia provides adequate level and duration of anesthesia in elderly and high risk patients undergoing lower abdominal and lower limb surgery -Indications: postoperative analgesia, chronic pain relief, previous spinal surgery, procedures of unpredictable length, significant cardiac disease, morbid obesity, difficult epi...

Blood loss is affected by central venous pressure during Hepatectomy. When central venous pressure is maintained at <5 mm Hg, blood loss is predictably lower than when central venous pressure is> 6 mm Hg. In the original publication describing low central venous pressure approaches to hepatic resection, median blood loss was only 200 mL, with most patients in the low central venous pressure study group not requiring transfusion. In contrast, when central venous pressure was ≥ 6 mm Hg, median blood loss was 1 L and half of the patients required transfusion. Low central venous pressure approaches affect outcomes beyond transfusion and blood loss, as reflected in longer hospital stays for patients whose central venous pressure was >6 mm HG during hepatic resection. Low central venous pressure anesthesia apparently is safe with respect to renal function. Only 3% of patients experience any degree of permanent renal dysfunction after hepatic resection using a low central v...

Although regional central conduction blockade, and especially spinal anesthesia, has been implicated in the exacerbation of MS , the studies are very small. Local anesthetic neurotoxicity has been speculated as being a more likely in nerves which are demyelinated, i.e. in MS patients. As such, theoretically epidural anesthesia may be less of a risk as concentrations of local anesthetic in the white matter of the spinal cord are lower than with spinal anesthesia Overall, however, the use of epidural anesthesia appears safe. Bader et al. noted that in women who received epidural anesthesia for vaginal delivery, relapse rates were similar to those who received local infiltration. Additional prospective and randomized studies will need to be conducted to evaluate the true relationship between regional anesthesia and MS exacerbations.

Severely elevated blood pressure (BP) and aggressive BP reduction are both associated with poor outcome in acute ischemic stroke (AIS). Because many stroke patients have long-standing hypertension, blood pressure lowering may result in cerebral hypoperfusion and worsening ischemia.  It is generally accepted that elevated blood pressures should not be lowered, unless: the patient has received thrombolytic treatment has a hypertensive emergency (aortic dissection, hypertensive encephalopathy, acute renal failure, acute pulmonary edema, or acute myocardial infarction);   contraindication to elevated blood pressure, such as recent surgery. The American Stroke Association guidelines recommend that antihypertensive agents should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg . If patients have received thrombolytic therapy, the guidelines advocate maintaining systolic blood pressure...

Acute heart failure syndrome (AHFS) spectrum can be divided into 5 groups as regards therapeutic management :  (i) Dyspnoea + /- congestion with elevated systolic blood pressure (SBP)>140 mmHg, usually with abrupt onset (acute pulmonary oedema) APO (most frequent type) (ii) Dyspnoea + /- congestion with normal SBP 100-140 mmHg, usually with gradual onset predominant systemic oedema and milder APO (iii) Dyspnoea + /- congestion with low SBP <100 mmHg, with predominant cardiogenic shock or end-stage cardiac failure (most fatal type) (iv) Dyspnoea + /- congestion with signs of ACS such as chest pain (v) Isolated RV failure usually without APO. Treatment aims Decrease left ventricular diastolic pressure, by decreasing systemic vascular resistance and improving systolic and diastolic functional reserve. Promote coronary blood flow. Correct acute respiratory failure. In-hospital mortality for APO is up to 12%, with one-year mortality up to 40%. Drugs Ni...

Monopolar TURP The conventional gold standard for TURP was the monopolar electrode resectoscope. With the monopolar electrode, layers of prostatic tissue are resected with a cutting current transmitted through a single-limb electrode which exits the patient by way of a grounding pad. A non-electrolyte bladder-irrigating solution is required to avoid dispersion of the electrical current as well as tissue damage at the site of prostatic resection. TURP syndrome is a potentially serious complication which can occur when a nonelectrolyte, hypoosmolar bladder-irrigating solution is used. Bipolar TURP Bipolar TURP electrode technology incorporates a continuous loop electrode to resect prostatic tissue of BPH. This surgical tool is designed to contain the inflow and outflow of current via the resectoscope for prostatic tissue resection. By being completely self-contained within the bipolar unit, the current is prevented from passing through the patient. The advantage of this system is tha...

Here is the list of the different causes that elevate Troponin..as you will see ,not only ACS that result in Troponin elevation: Reasons for acutely elevated Troponin: ACS Acute heart failure PE Stroke Aortic dissection Tachyarrhythmias Shock Sepsis Perimyocarditis Endocarditis Tako-tsubo cardiomyopathy Cardiac contusion Strenuous excercise Sympathomimetic drugs Chemotherapy   Agewall S, Giannitsis E, Jernberg T, et al. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011;32:404-411.