sedationstation

" von Willebrand treatment is Desmopressin".... This what we all learned in the Med school, this statement passover important facts in von Willebrand disease.vonWillebrand disorder has many subtypes and some of these subgroups respond to Desmopressin different than we repeat  for long years.. here is the missing Facts about Desmopressin and von Willebrand Disorder: DDAVP is the treatment of choice of von Willebrand type 1..right.. But... DDAVP can be deleterious if given to patients with vWD type 2B causing thrombocytopenia. Patients with vWD type 3 do not respond to DDAVP at all... Now it is the time to change the starting statment... "Von Willebrand type 1 treatment is Desmopressin"

This is a summary of the relation between LVAD and Different valvular Disorders: Mitral insufficiency is not an important issue since after LVAD insertion the left ventricle is completely unloaded and the end-diastolic pressure approaches to zero. Mitral stenosis should be corrected since it may interfere with LVAD filling. Tricuspid insufficiency should be treated because LVAD filling and success depend on right ventricular forward flow. Severe aortic valve insufficiency produces a “vicious-circle circulation” and device output returns again and again to the left ventricle via the incompetent aortic valve. S evere aortic stenosis should always be corrected before permanent cardiac replacement because these patients often have adequate myocardial reserve, even with very low preoperative ejection fractions and severe congestive heart failure

Nasal trumpets Their contemporary use is commonly limited to the relief of upper-airway obstruction in two circumstances: 1) after extubation of the trachea in a spontaneously breathing patient, or 2) during mask ventilation when an oral airway (and jaw lift) has failed to produce an acceptable airway. It has not been previously reported that a standard, single-lumen nasopharyngeal airway could be used effectively to deliver positive-pressure ventilation as a rescue device in the cannot-ventilate/cannot-intubate scenario. Another important use of the nasal trumpet is what is called the modified Nasal trumpets method or the MNT. In MNT  The materials used consisted of a 30 or 32 French soft nasal airway (trumpet) and a 7.5- or 8-mm ETT connector. The ETT connector was inserted into the flared or proximal end of the nasal airway. The mating of the ETT connector to the nasal trumpet can occur quickly.Then you use this "Supraglottic"tool to d...

Definitions vary… They include: 10 unit transfusion in 24 h transfusion of an entire blood volume in 24 h replacement of 50% blood volume over 3 h  1 adult bag of platelets is equivalent to 4 units PRBCs for the purposes of maintaining the 1:1 ratio. Note that the 1:1:1 concept is mainly supported by the fact that it makes sense pathophysiologically and by retrospective and observational studies. It has not been conclusively proven in the way that a large double-blind randomised controlled trial would. Indeed, there are concerns that at least some of the perceived benefit of hemostatic resuscitation and the ’1:1:1′ ratio is due to survivor bias . Tranexamic acid an antifibrinolytic that works by competitively inhibiting the activation of plasminogen to plasmin plasmin is responsible for the degradation of fibrin. Given that tranexamic acid is cheap, one of the few interventions with proven mortality benefit (NNT = 67) and few adverse effects I think clinicians...

This comprehensive review published in Circulation in 2007 gives a good insight into the problem of the cardiovascular risk and the use of COX 2 inhibitors or conventional NSAIDs. It covers the basic pharmacology as well as the clinical use of this important group of drugs. Importantly, it looks at the different CVS risk of the conventional NSAIDs. Diclofenac has a high risk (>2) while naproxen is low risk . For more information, click on the link below: NSAIDS and Cardiovascular safety

Endotracheal tube and laryngeal mask airway cuff pressures can exceed critical values during ascent to higher altitude.   OBJECTIVES: Tracheal mucosal perfusion is compromised at an endotracheal tube (ETT) cuff pressure of 30 cm H(2)O, and blood flow is obstructed at a pressure of 50 cm H(2)O. METHODS: We measured the change in pressure of air-filled cuffs of 6.0 and 7.5 ETTs and a size 4 laryngeal mask airway (LMA) from sea level to 2400 m. The ETTs and LMA cuff measurements were done with the devices uncontained, and an additional 6.0 ETT was placed in a 10-mL syringe barrel to mimic placement in a trachea. This restricted cuff expansion simulating what would occur when it is placed within the trachea. The pressure of fluid-filled 6.0 ETT cuffs was also measured. RESULTS: Intracuff pressure increases linearly with increasing altitude, in all air-filled ETT and LMAs. Water-filled cuffs demonstrated no significant change in pressure with changes in altitude. The rate of ETT ...

Paracetamol is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo. Level I Cochrane review Non-selective NSAIDs are effective in the treatment of acute postoperative and low back pain, renal colic and primary dysmenorrhoea  (Level I Cochrane review ) With careful patient selection and monitoring, the incidence of nsNSAID-induced perioperative renal impairment is low.(Level I chocrane review) Non-selective NSAIDs do not increase the risk of reoperation for bleeding after tonsillectomy in paediatric patients. (Level I Cochrane review) Coxibs do not appear to produce bronchospasm in individuals known to have aspirinexacerbated respiratory disease.(level I) Paracetamol given in addition to PCA opioids reduces opioid consumption but does not result in a decrease in opioid-related side effects.( Level I) Preoperative coxibs reduce postoperative pain and opioid consumption, and increase patient satisfaction.(level I) Perioperative non-sele...

Codeine has been an historically popular drug. This has been particularly due to its availability in many over-the-counter combination analgesic drugs such as Panadeine and cold-and-flu remedies. The problem is that codeine is a pro-drug for morphine which depends on the highly variable pharmacokinetics of individual patients. This editorial from the CMJ argues that it is better and safer for patients to avoid codeine and just use a predictable opioid such as morphine or oxycodone .

First Anatomy... The spinal cord ends at the level of L 1 -L 2 . The distal part of the cord it the conus medullaris and its distal end continues as the filum terminalae. Distal to the conus, there are nerve roots and endings that look like a horse’s tail (thus the term canda equina). Cauda Equina Syndrome occurs when there is compression of the lumbosacral nerve roots. Second what causes compression? -Central lumbar disc protrusion of L 4/5 or L 5 S 1 - Lumbar canal stenosis - Trauma - Tumours – metastases – lung, breast, renal - Infection – abscess - Haematoma Clinical Picture: Patients can present with a pure canda equina or conus medalluris syndrome, or a mixture of both. Canda equina syndrome is really a peripheral nerve lesion. Conus medullaris Syndrome may have some upper motor neurone(UMN) signs and present with increased tone and reflexes (UMN) and bilateral signs . I In terms of the diagnosis, differentiating between ...

The main principles of treatment encompass: providing supplemental oxygen to help avoid hypoxemia, and to improve oxygenation, anticoagulation for the prevention of further pulmonary emboli, and vasodilatory therapy to reverse the vasoconstrictive component of pulmonary hypertension. The goal of oxygen therapy (supplementation) is to maintain oxygen saturation over 90% at all times to attenuate hypoxic pulmonary vasoconstriction. Therefore, supplemental oxygen may be necessary during periods of exertion or at rest as well. Long term Coumadin (warfarin) therapy has been shown to improve survival of the patients suffering from primary pulmonary hypertension . Prothrombin time needs to be monitored and the desirable level of anticoagulation is to keep the INR level between 2-3. For the reversal of pulmonary vasoconstrictive component of pulmonary hypertension (if present) both calcium channel blockers and prostacyclines have been used with somewhat limited succe...

--Thoracic (above the T12 dermatome) epidural local anesthetics (e.g. bupivacaine) can have clinically significant effects to decrease the duration of ileus after abdominal surgery. --The most optimal post-op analgesia , in terms of minimizing post-op ileus, appears to be a combination of low-dose epidural bupivacaine plus morphine. --In order for this combination to be effective, it should be delivered via a thoracic epidural catheter, ideally with the tip of the catheter as close as possible to the dermatome in the middle of the surgical incision. (e.g. T10 for an upper abdominal incision) Safeguarding intestinal perfusion is a critical issue in the maintenance of intestinal function and integrity of the mucosal barrier. The effect of epidural bupivacaine (5mg/ml) on intestinal blood flow was studied with laser Doppler flowmetry in patients during large bowel resection. In the colon , blood flow increased in 13 out of 15 patients, which was significant at the 1 per cent level. The av...

There is no evidence that bed rest is beneficial in the treatment and prevention of postdural puncture (Level 1 evidence (cochrane review)) The incidence of postdural puncture headache is reduced by using small-gauge spinal needles and/or a non-cutting bevel.level 1 evidence. Further high quality trials are required to determine the efficacy of epidural blood patch administration in the treatment of postdural puncture headache (Level 1).However benefit is likely Frequent use of analgesics, triptans and ergot derivatives in the treatment of recurrent acute headache may lead to medication overuse headache.

Radiotherapy and bisphosphonates are effective treatments of acute cancer pain due to bone metastases. Acute pain in patients with cancer often signals disease progression; sudden severe pain in patients with cancer should be recognised as a medical emergency and immediately assessed and treated. Cancer patients receiving controlled-release opioids need access to immediate-release opioids for breakthrough pain; if the response is insufficient after 30 to 60 minutes, administration should be repeated. Breakthrough analgesia should be one-sixth of the total regular daily opioid dose in patients with cancer pain (except when methadone is used, because of its long and variable half life).

In a cochrane review, 11,444 women in 15 randomized trials were recruited from a mix of high, middle, and low income countries. The largest is the 33-country MagPie Trial comparing intravenous magnesium to placebo. The study was published in 2002 and at >10,000 subjects accounts for more than 87% of those in the review. The use of magnesium sulfate was associated with a greater than 50% relative reduction in the risk of eclampsia (RR 0.41).  As noted by the reviewers, a similar reduction in maternal mortality (RR 0.54) was also found, though the absolute number of deaths was small which may have kept this reduction from reaching statistical significance.  A reduction in placental abruption was also noted (RR 0.64) as well as a small increase in the rate of cesarian section. No differences were seen in child outcomes. As a secondary outcome, magnesium sulfate was more effective than phenytoin for reducing risk of eclampsia in 3 trials (RR 0.08) but also increase...

When I read today the football news  highlighting the cardiac event of football player "Muamba",I preferred to share with you the following piece.. An autopsy series in US communities evaluated young patients (avg age 36 years old) who died of "non-natural" causes revealed coronary atherosclerosis in > 80% of the autopsy sample, with 8% having significant obstructive disease. The bottom line is simple....be wary of discounting the risk of ACS purely based on a patient's age. The HPI is the most important factor in predicting ACS. References Nemetz PN, et al. Recent trends in the prevalance of coronary disease: a population-based autopsy study of nonnatural deaths. Arch Intern Med 2008;168:264-270 . Arbab-Zadeh A, et al. Acute coronary events. Circulation 2012;125:1147-1156.

Up to 80% of patients with low glomerular filtration rates (GFR), and in the absence of acute coronary syndromes or congestive heart failure, have positive values for TnT, regardless of whether or not they receive dialysis treatment. On the other hand, one large study that included more than 700 patients found the prevalence of TnI to be only 0.4-6% depending on the cut-off value chosen . These results suggest that a positive TnT may represent a common and benign incidental finding in patients with impaired renal function, whereas a positive TnI occurs only in the setting of an acute coronary event. Tsutamoto et al. performed a very elegant study measuring the transcardiac TnT gradient by measuring levels in both the aortic root and coronary sinus . They classified 258 patients with congestive heart failure as having either normal or low GFR. Despite the finding of markedly elevated levels of TnT in the patients with low GFR compared to the patients with normal renal function, th...

A recent quantitative review suggests that depressive symptoms contribute a significant independent risk for the onset of coronary disease, a risk (odds ratio [OR] = 1.64) that is greater than the risk conferred by passive smoking (OR = 1.25) but less than the risk conferred by active smoking (OR = 2.5). 1 Patients with coronary heart disease who also display depressive symptoms have an increased risk of mortality.2 The Neurological Outcome Research Group conducted a prospective study of 555 CABG patients for 6 months and showed that, after adjustment for other risk factors, depression was associated with a 2- to 3-fold increase in risk of death. 3 1. Wulsin LR, Singal BM. Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review. Psychosom Med 2003;65(2): 201–210 2. Barth J, Schumacher M, Herrmann- Lingen C. Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosom Med 2004;66(...

Wellens’ Syndrome: Recent history of chest pain Little or no elevation of cardiac enzymes Biphasic T-wave in V2-3 Minimal (<1mm), if any, ST elevations Highly specific for LAD occlusion specificity  89% sensitivity  69% positive predictive value of 86% The recommended treatment for such patients is an early invasive approach, either with cardiac catheterization with angioplasty or coronary artery bypass surgery. References 1-de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982, 103:730-6.  2-Haines DE, Raabe DS, Gundel WD, Wackers FJ. Anatomic and prognostic significance of new T-wave inversion in unstable angina. Am J Cardiol 1983, 52:14-8

Anesthetic Plan... Fetal surgical cases require team work. These include: pediatric general surgery, obstetrics, pediatric anaesthesia, obstetric anaesthesia, cardiology, radiology, neonatology, neonatal nursing and operating room nursing. Preoperative preparation Standard anesthtic history, physical examination and history of symptoms of aortocaval compression or gastroesphageal reflux. Cross-matched blood for the mother. O-negative blood for the fetus. Maternal antibodies to blood antigens can cross the placenta. Specific fetal information as location of the placenta, fetal weight, the actual disease process and pathophysiology. Anesthesia for minimally invasive These cases are the most variable in need for maternal analgesia and anesthesia and in the need for fetal analgesia or immobility. An anesthestic plan can range from local infiltration to sedation to neuroaxial to general anesthesia. The current practice include maternal fasting, IV catheter, aspiration prophylaxis and tocoly...

Perioperative Management of ICDs press on the following link                                                                           Click Here

In 1963 Sir William Liley performed the first successful fetal procedure, consisting of an intraperitoneal blood transfusion. In the past two decades, fetal surgery has become popularized in the management of congenital anomalies that may lead to complication at delivery. Fetal surgical procedures can be divided into: 1.Minimally invasive intervention. These are the most frequently performed fetal surgical procedure. The access may be as minor as one small gauge radio frequency probe; the timing of these procedures is early or mid-gestation. 2. Open mid-gestation surgery. A maternal laporotomy is performed; the incision is usually transverse and cephalic than that performed in c/section, the necessary anatomy of the fetus is only delivered via the hysterotomy. 3. EX-utero intrapartum therapy (EXIT) procedure. These procedures are performed at or near term to optimize lung maturity. Surgical intervention is performed before the umbilical cord is clamped while on placental bypass. The ne...

Nonsmokers have 1% to 3% carboxyhe­moglobin (COHb) levels Smokers have 1% to 8% COHb level Fire victims near 100% CO levels Frequent imme­diate cause of death CO affinity for hemoglobin 250 times that of O 2 Even small amounts of CO can produce equal levels of oxyhemoglobin and COHb Pulse oximeter reads COHB as O2HB..you need Co-oximeter or you should measure the SaO2 Causes left shift of oxyhemoglobin dissociation curve (less O 2 released to bloodstream) Early treatment with O 2 decreases mortality Continue 100% oxygen therapy until the patient is asymptomatic and HbCO levels are below 10%. In patients with cardiovascular or pulmonary compromise, lower thresholds of 2% have been suggested. Consider immediate transfer of patients with levels above 40% or cardiovascular or neurologic impairment to a hyperbaric facility, if feasible. Persistent impairment after 4 hours of normobaric oxygen therapy necessitates transfer to a hyperbaric center. Pregnant patients...

      Practice guidelines for central lines insertion                                                            Click Here   Anesthesiology: March 2012 - Volume 116 - Issue 3 - p 539–573

Use the following hypothetical case as a starting point. A morbidly obese (BMI 48.8) woman in her early 20’s with no significant past medical history presented for relatively minor, superficial, elective surgery involving skin grafting. In the pre operative holding area her vital signs were normal except for a pulse of 142. An EKG showed sinus tachycardia. The patient notes significant anxiety. The patient is given 1 L crystalloid and 2 mg midazolam and her pulse came down to 128. The decision was made to proceed to the operating room and an uneventful induction of general endotracheal anesthesia ensued. After a second liter of fluid, the heart rate remained in the 130s and an intraoperative venous blood gas was sent. The results were remarkable for a pH of 7.25; a calculated bicarbonate of 14, and a glucose of 486. The pt was given a 10 unit IV insulin bolus and started on an insulin drip. She received an additional liter of IV fluid and was admitted for further evaluation of her hype...

There´s evidence of intravenous lipid emulsions being effective antidotes in systemic local anesthetic toxicity. The most popular theory on the mechanism of action being the so called ‘lipid sink effect’. The idea is that lipid globules sequester lipophilic substances, thereby reducing plasma concentrations of the toxin. It is a popular theory, but so far the – mostly animal – studies are conflicting regarding the real mechanism of action.  In fact, we don’t even know if it’s an effective therapy.  A study in Anestesia Analgesia in 2011 tries to shed some light. The study Pigs were injected with toxic systemic doses, of either Bupivacaine or Mepivacaine. They were then randomized into treatment with either Ringer’s Acetate or lipid emulsion. Plasma concentrations and hemodynamic effects (the treatment parameters) were recorded while the pigs were being treated. Results There were no overall significant differences in Bupivacaine or Mepivacaine plasma concentrat...

The bougie works.  Most studies report 10-15% increase in first pass success rates. It’s cheap and the technique is easy to learn There is however one big problem with the bougie, a problem it shares with other tube-over-guide techniques – the arythenoid hang-up. The space between the bougie and the tube tip becomes a ‘hook’ that snags the arythenoid.And the result will be "I can not deliver the tube" and in  worst-case-scenario the whole intubation attempt is abandoned . The fix of this common problem is in the following Image... In this image Retract the tube a centimetre or so. Then turn the tube counter-clockwise 90 degrees so that the tip and the ‘hook’ is anterior and clear of the arythenoids. Then pass the tube between the vocal cords.

How long should someone requiring cardioversion for atrial fibrillation be anticoagulated for? How should I provide thromboprophylaxis for this intubated patient? This patient with submassive pulmonary embolism isn’t hypotensive yet. Can I thrombolyse them? Can I? There’s a large superficial vein thrombosis in that limb – is anticoagulation indicated? This asymptomatic patient on warfarin has an INR of 9.0 – should I reverse them? Do I need to add Vitamin K if I’ve reversed warfarin with prothrombin complex concentrate? The answers to these – and many, many more – questions are provided in this most comprehensive guidelines published in Chest. 2012 Feb;141(2 Suppl)                                              Press on the following link    ...

Myocardial reperfusion, (spontaneous or via lytics or PCI), affect the kinetics of troponin. Patients with ST-segment elevation myocardial infarction who achieve an effective reperfusion have a faster return to normal – called ‘‘wash-out phenomenon’’. The ratio between the concentrations at these two points can be used to discriminate between successful and unsuccessful reperfusion. In general, the greater the ratio (at least 5), the more likely it is that reperfusion has occurred