sedationstation

May be you have to think of new place to put the pulse oximetry... In this paper the authors describe s uccessful use of pharyngeal pulse oximetry with the oropharyngeal airway in severely shocked patients. Pharyngeal oximetry with the oropharyngeal  airway inserted in two patients with severe shock in whom finger pulse oximetry failed. One patient was a 50-year-old man with septic shock and the other a 32-year-old woman with haemorrhagic shock. In both patients, an oropharyngeal airway with a pediatric pulse oximeter probe was inserted adjacent to the tracheal tube. (see the photo) A good waveform was obtained and oxygen saturation was 0-2% lower than arterial samples whereas finger pulse oximetry saturation was unobtainable or much lower than arterial oxygen saturation. Pharyngeal oxygen saturation with the oropharyngeal airway is feasible and more accurate than finger oximetry in low perfusion states airway in two patients with severe shock in whom finger pulse oxi...

"A Mixed (long- and Medium-chain) Triglyceride Lipid Emulsion Extracts Local Anesthetic from Human Serum In Vitro More Effectively than a Long-chain Emulsion" Anesthesiology, February 2012 Researchers in the U.K. analyzed the difference between mixed (medium- and long-chain) and long-chain lipid emulsions, for their ability to extract local anesthetic from serum. They concluded that the type of emulsion may make the reversal more effective. The authors used human drug-free serum and added bupivacaine, ropivacaine, or mepivacaine each at a concentration of 10 µg/ml, or bupivacaine 100 µg/ml at pH 7.4, and, in another experiment, bupivacaine 10 µg at pH 6.9. 20% Intralipid®, which has long-chain triglycerides, or 20% Lipofundin®, which contains a 50-50% mixture of medium- and long-chain triglycerides, was then added at 1, 2, or 4% of total volume. The mean decrease in serum drug concentration was then calculated. The authors’ in vitro model showed overall that Lipofundin® was ...

beta blockers glucagon, high-dose insulin euglycaemic therapy (HIET)   bupivacaine sodium bicarbonate, intralipid   benzodiazepines flumazenil   glipizide glucose, octreotide   heparin protamine   hyoscine physostigmine   magnesium calcium   organophosphate atropine, pralidoxime   opiates naloxone   paracetamol n-acetylcysteine   verapamil calcium, high-dose insulin euglycaemic therapy   warfarin vitamin K

Dr Sprung et al published a paper in the Mayo Clinic Proceedings entitled: ”Attention-Deficit/Hyperactivity Disorder After Early Exposure to Procedures Requiring General Anesthesia” Abstract Objective To study the association between exposure to procedures performed under general anesthesia before age 2 years and development of attention-deficit/hyperactivity disorder (ADHD). Patients and Methods Study patients included all children born between January 1, 1976, and December 31, 1982, in Rochester, MN, who remained in Rochester after age 5. Cases of ADHD diagnosed before age 19 years were identified by applying stringent research criteria. Cox proportional hazards regression assessed exposure to procedures requiring general anesthesia (none, 1, 2 or more) as a predictor of ADHD using a stratified analysis with strata based on a propensity score including comorbid health conditions. Results Among the 5357 children analyzed, 341 ADHD cases were identified (estimated cumulative incidenc...

Soon Dopamine will be part of history of medicine... This is because of  two main  reasons: First, renal sparing low dose dopamine was disproven. Second two big studies published in 2010 pushed Dopamine  further into darkness The SOAP II study had 1600 patients and another one printed in Shock had 250 patients. Both studies randomised patients in shock and in need of vasopressors to either dopamine or noradrenaline. Both made the same conclusion. There was no significant overall difference in 28-day mortality, but the dopamine group had significantly higher incidence of arrhythmia. The dopamine sub-group with cardiogenic shock actually did show a higher mortality compared to noradrenaline. Cardiogenic shock is exactly the group where dopamine was recommended by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines. So as you see Dopamine is suffering to survive...this may not be the end of Dopamine,but for the ...

It is theoretically sound to avoid N2O during laparoscopy for at least two reasons: First, it diffuses into the abdominal cavity in concentrations sufficient to support combustion of intestinal gas.1 second, it will diffuse into CO2 bubbles and emboli,increasing their size and potenial for an obstructive event. Adequate muscle relaxation is required during laparoscopy so that: Spontaneous respiratory effort does not impair the surgical procedure or risk increasing the gradient for embolic gas to enter the central circulation Most studies but not all report a decrease in left ventricular function and cardiac output (cardiac output decreased 7–24%). In addition, with assumption of the reverse Trendelenburg position, cardiac index may decrease by 50% of preanesthesia and preinsufflation values. Venous stasis of the lower extremities also occurs, with attendant concerns for embolic phenomenon 3,4 Relatively small CO2 emboli have been detected by transesophageal echocardiography...

Intercostal nerve block is an effective technique to provide postoperative analgesia without central respiratory depression and to attenuate the decrease in pulmonary function after thoracic surgery. Postthoracotomy pain is not completely managed with intercostal analgesia; it requires supplemental use of parenteral opioids or NSAIDs. Intercostal nerve block can be performed intraoperatively by intrathoracic injection or percutaneously by the anesthesiologist. Nerve blocks are performed at the levels above and below the site of chest tube insertion and incision. Nerve blocks are performed by injection of 2–3 mL  of bupivacaine 0.5% with epinephrine (1:200,000 concentration). Because the average duration of these nerve blocks is 4–8 hours, placement of indwelling catheters in the intercostal space is used to provide analgesia up to 6 days Complications of this technique are few but include pneumothorax, local anesthetic toxicity, and neuroaxonal spread of local anestheti...

Causes of cardiac arrest in pregnancy: -Amniotic Fluid Embolism -Acute anaphylaxis -Massive obstetric hemorrhage -Magnesium overdose, toxicity -Cardiac patients with fixed cardiac output lesion -Trauma -Anesthesia related: catastrophic airway events, total spinal The usual drugs and doses recommended in ACLS algorithms should be used in parturients. No drugs should be avoided , no dose changed in order to avoid potential adverse effects on neonate or fetus. The rescuer should place their hands 1-2 cm higher on the sternum of a woman at term to obtain better cardiac output with compression. Left Uterine displacement is needed. A liter of maternal blood can be mobilized from venous system to cardiac output Aorto-caval compression by the gravid uterus profoundly decreases venous return that will reduce cardiac output further during the low cardiac output state produced by closed chest compression Even with perfect adherence to ACLS algorithms, ...

Colchicine reduces postoperative atrial fibrillation: results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy. Inflammation and pericarditis may be contributing factors for postoperative atrial fibrillation (POAF), and both are potentially affected by antiinflammatory drugs and colchicine, which has been shown to be safe and efficacious for the prevention of pericarditis and the postpericardiotomy syndrome (PPS). The aim of the Colchicine for the Prevention of the Post-Pericardiotomy Syndrome (COPPS) POAF substudy was to test the efficacy and safety of colchicine for the prevention of POAF after cardiac surgery. METHODS AND RESULTS: The COPPS POAF substudy included 336 patients (mean age, 65.7±12.3 years; 69% male) of the COPPS trial, a multicenter, double-blind, randomized trial. Substudy patients were in sinus rhythm before starting the intervention (placebo/colchicine 1.0 mg twice daily starting on postoperative d...

General anesthesia has an inhibitory effect on neurotransmission and, therefore, on the EP. The effect of anesthetics is greater on synaptic transmission than on axonal conduction. For this reason, responses recorded from polysynaptic pathways (e.g., cortical recordings) are affected by anesthesia to a much greater extent than those recorded from oligosynaptic pathways (e.g., spinal cord and subcortical recordings). ” All volatile anesthetics produce a dose-dependent increase in SSEP latency and a decrease amplitude. All volatile anesthetics, even at concentrations above 1.0 MAC, only minimally affect the sub-cortical waveform, resulting in high recordability and reliability. The effect of volatile anesthetics on cortical SSEP amplitude is compounded by nitrous oxide. Intravenous anesthetics generally affect SSEPs less than inhaled anesthetics do. Etomidate and ketamine increase SSEP amplitude. Propofol, midazolam, and barbiturates have a moderate depressant effect on SSEP am...

In a Prospective cohort of 361 intensive care units from 20 countries. A total of 5183 patients mechanically ventilated for more than 12 h. Barotrauma was present in 154 patients (2.9%). The incidence varied according to the reason for mechanical ventilation: 2.9% of patients with chronic obstructive pulmonary disease 6.3% of patients with asthma   10.0% of patients with chronic interstitial lung disease (ILD) 6.5% of patients with acute respiratory distress syndrome (ARDS)   4.2% of patients with pneumonia Logistic regression analysis identified as factors independently associated with barotrauma asthma [RR 2.58 (1.05-6.50)]   ILD [RR 4.23 (95%CI 1.78-10.03)]   ARDS as primary reason for mechanical ventilation [RR 2.70 (95%CI 1.55-4.70)]   ARDS as a complication during the course of mechanical ventilation [RR 2.53 (95%CI 1.40-4.57)] Case-control analysis showed increased mortality in patients with barotrauma (51.4 vs 39.2%; p=0.04) and prolonged ICU stay. In a ...

Tourniquets have significant risks, and these risks and the strategies to minimize them should be part of the knowledge base of all practicing anesthesiologists. Limb exsanguination causes an increase in central blood volume that is reflected as a transient rise in central venous pressure. Tourniquet inflation also causes an increase in afterload. Patients with diminished cardiac function may not be able to tolerate this combined insult of increased preload and afterload. After tourniquet deflation, preload decreases acutely as blood reenters the affected extremity, which undergoes a period of postischemic reactive hyperemia. This is accompanied by an acute decrease in afterload that often produces hypotension. During limb ischemia, oxygen and high-energy phosphate stores decrease progressively, and carbon dioxide and lactic acid levels rise as ischemic tissues convert to anaerobic metabolism. The pH of the ischemic limb decreases as the duration of ischemia increases. After ...

TPN is usually slowed prior to anethesia primarily to avoid complications from excessive (hyperosmolarity) or rapid decrease (hypoglycemia) in infusion rates in the busy operating area. That said, because abrupt discontinuation may lead to severe hypoglycemia, TPN must be turned down gradually. According to Miller, Dr. Michael F. Roizen has adopted the following: " Infusion of TPN or enteral nutrition is reduced the night before surgery and a 5% or 10% dextrose solution is substituted preoperatively. If serum glucose, phosphate, and potassium concentrations measured preoperatively are abnormal, they are restored to whithin normal limits. Strict asepsis is maintained. Conversely, one should continue infusing the TPN solution by using a pump system or enteral nutrition while strictly maintaining its normal rate and asepsis, administering all fluids through a different IV site and performing a rapid sequence intubation (for those who received enteral nutrition)." The most comm...

Magnesium is a divalent cation that competes with calcium and inhibits many calcium-dependent processes. With regard to muscle relaxation, it is known to:  (1) antagonize calcium either at the motor end plate or cell membrane, reducing calcium influx into the myocyte  (2) Compete with calcium for low-affinity calcium binding sites on the outside of the SR membrane and prevent the rise in free intracellular calcium concentration (3) Attenuate the: release of Ach at NMJ, sensitivity of the motor endplate to Ach, and excitability of the muscle membrane. Implications for and potential interactions with anesthesia care are many. Magnesium may increase the likelihood of hypotension with epidural use (studies with gravid ewes demonstrated reduced maternal MAP, but not uterine blood flow or fetal oxygenation during epidural). Magnesium can potentiate the effects of both depolarizing and non-depolarizing muscle relaxants (probably not as much with depolarizing) increasing p...

The occurrence of ‘tet spells’ is generally an indication for cardiac surgery, at least in the long term. Surgery may be palliative or corrective. Palliative traetment include  BT Shunt   and  modified BT Shunt BT shunt : It consists of anastomosis of the subclavian artery to the pulmonary artery, bypassing the pulmonary stenosis so that a part of the hypoxemic aorta blood is supplied to the hear Modified BT Shunt   is a surgically-created (goretex) conduit between a subclavian artery and the pulmonary artery. It improves blood flow to the pulmonary circulation by providing a route for returning systemic blood that bypasses the right ventricular outflow obstruction. Following a modified BT shunt, arterial oxygen saturations of about 70 to 85% are optimal as they indicate relative balance between pulmonary and systemic blood flows. Definitive repair involves closure of the ventricular septal defect (VSD) and opening up of the obstructed right ve...

The presence of coronary artery disease (CAD) increases with age.  Anatomic coronary artery disease can be detected in more than 50% of people older than 70 years of age. CAD in the aged is more severe and  diffuse than in younger patients. There are differences in prevalence by gender: at 65 years of age, CAD is more prevalent in men than in women; by age 80, the prevalence of symptomatic congestive heart disease is nearly equivalent in men and women. Despite the high prevalence of anatomic CAD, only 10–20% of people older than 65 years of age carry a diagnosis of active CAD. One study reported that 37% of elderly patients had subclinical CAD, making it as common as clinically overt CAD in older adults. Furthermore, in this study, the presence of subclinical CAD was significant as it strongly predicted overt CAD, stroke, and mortality, even after adjustment for traditional cardiovascular risk factors.

Your response to Cocaine overdose: Drug induced hypertensive emergencies are often short lived, and often aggressive therapy is not needed. Cocaine in particular is noted to be associated with hypertension, ventricular arryhthmias, and acute coronary syndromes. The important key to the treatment of this toxicity is avoiding the use of beta blockers (Class III), especially nonselective agents such as propranolol, as this allows for unopposed alpha adrenergic stimulation and worsening of the hypertension. Benzodiazepines (Class IIa) in addition to a short acting, titrateable antihypertensive such as nitrates (Class I) should be the first line of therapy. Should the hypertension be refractory, the use of alpha adrenergic blocking agents (Class IIb) may be considered, keeping in mind that tachycardia and hypotension may result . Your response to tricyclic overdose Tricyclic antidepressants (TCA) are sodium channel blockers that may result in prolongation of ventricular conduct...

Effect of the bevel direction of puncture needle on success rate and complications during internal jugular vein catheterization. Crit Care Med. 2012 Feb;40(2):491-4. OBJECTIVE: Artery puncture and hematoma formation are the most common immediate complications during internal jugular vein catheterization. This study was performed to assess whether the bevel-down approach of the puncture needle decreases the incidence of posterior venous wall damage and hematoma formation during internal jugular vein catheterization. PATIENTS: Three hundred thirty-eight patients for scheduled for thoracic surgery requiring central venous catheterization in the right internal jugular vein. INTERVENTIONS:  Patients requiring internal jugular vein catheterization were enrolled and randomized to either the bevel-down group (n = 169) or the bevel-up group (n = 169). All patients were placed in the Trendelenburg position with the head turned to the left. After identifying the right internal jugular vein...

When you see beyond monitor...  A very nice lecture tells you Why we do diagnostic errors ..with a plenty of real clinical examples…good resource for all residents in all levels to review the basics of Hemodynamic monitoring…and more… It is one of the best lecture i have ever made.. I hope that you will like it Ahmad M. Abou Leila                                                        Click Here or Copy Paste the following link http://www.slideshare.net/doctorabouleila/when-you-read-beyond-the-monitor-share-version

Physiological derangements after brain death are an extension of those which occur with severe brain injury. Initial dysautonomia and catecholamine release -> labile HT and tachycardias Subsequent hypotension due to neurogenic decrease in SVR and / or myocardial dysfunction Neurogenic diabetes insipidus Non-cardiogenic pulmonary oedema Hyperglycaemia Coagulopathy Poikilothermia Management includes a) Ventilatory control: Optimum ventilation strategy uncertain. Recommended aims: ·PaO2 > 100mmHg ·PaO2:FiO2 > 250 ·PaCO2 35 - 45mmHg ·Avoid pulmonary congestion ·Methylprednisone 15mg/kg may improve oxygenation ·Regular routine turning and tracheal toilet b) Circulatory control: ·Volume replacement - crystalloids tend to pulmonary oedema, starch compounds impair graft function ·Inotrope support . Adrenalin promotes hyperglycaemia, but may reduce acute graft rejection.Dobutamine ineffective. ·Short acting ß-Blocker may be used for significant tachycardias. Clonidine w...