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Flow–volume loops measured before Lap cholecystectomy (left ) and on the first postoperative  day after coaching and pain medication (right). The shift to the right indicates a fall in lung  volumes.  The smaller, but similarly shaped, loop indicates a restrictive process.

The arterial duct is one of the fetal shunts and is closed in 3-4  days in 90% of term and ‘well’ premature babies.  The duct closes  in response to a rise in oxygen tension after birth and a fall in  circulating prostaglandins.  Patent ductus arteriosus (PDA) is  seen in 50% of VLBW infants due to low oxygen tension,  continuing high prostaglandin levels, or abnormal stimuli such  as acidosis and expansion of the circulating volume. Aorto-pulmonary shunting though the PDA causes high  pulmonary blood flow, worsening RDS, cardiac failure and low  diastolic pressure.  PDA is a risk factor for intraventricular haemorrhage, necrotizing enterocolitis and CLD.  PDA typically  becomes symptomatic at 5-10 days as pulmonary vascular  resistance falls; it presents with worsening respiratory function,  bounding pulses, a continuous murmur and chest radiograph  that shows cardiomegaly and increased lung s...

Awarness occurance  reported to range from 0.2–1.0%, and is   probably underestimated.. Here are  the tips to avoid this complication....They are 12... Consider amnestic premedication (midazolam, scopolamine) Routine equipment checks: e.g., correct placement of vaporizer). End-tidal monitoring of volatile anesthetics with low-concentration alarm). Adequate dosing of induction agents. Use of appropriate volatile anesthetic con- sertion centration or propofol dose for maintenance. Realize potential for awareness with hypotension/ hypovolemia Judicious use of neuromuscular blocking agents combined with careful monitoring. Frequent checks of intravenous lines and pumps when using total intravenous anesthesia. Clear labeling of all syringes. Quiet, professional operating room atmosphere: minimize auditory input. Consider use of anesthetic depth monitor (Bispectral Index). Calm reassurance when strong po...

Your  patient has a central venous catheter inadvertently placed in his carotid. Do you pull-and-push?  This small case series suggests leaving it in and getting vascular repair is a better approach. Below is the Summary.. Background Percutaneous catheterization is a frequently-used technique to gain access to the central venous circulation. Inadvertent arterial puncture is often without consequence, but can lead to devastating complications if it goes unrecognized and a large-bore dilator or catheter is inserted. The present study reviews our experience with these complications and the literature to determine the safest way to manage catheter-related cervicothoracic arterial injury (CRCAI). Methods We retrospectively identified all cases of iatrogenic carotid or subclavian injury following central venous catheterization at three large institutions in Montreal. We reviewed the French and English literature published from 1980 to 2006, in PubMed, and selected stu...

The Trauma lethal triad   the Acidosis ,Hypothermia and Coagulopathy….is not the only triad leads to mortality….in an   interesting paper published this month   in anesthesiology a new Triple low identified that leads to   higher perioperative mortality rates…. The Triple low includes the Low Blood Pressure Low BIS index Low MAC In this Paper the authors used their institution’s hospital documentation system to evaluate the association between low mean arterial pressure (< 75 mm Hg), low bispectral index (< 45) and low anesthetic concentration (MAC < 0.8) with length of hospital stay and 30-day mortality. Almost 25,000 patients who underwent noncardiac surgery between January 6, 2005, and December 31, 2009, at the Cleveland Clinic were studied. Bispectral index monitoring was used for all patients, all patients had single volatile agent, and all were at least 16 years old. Those with triple low values stayed longer in the hospital. Thi...

  New studies are utilizing mild therapeutic hypothermia as a treatment option in cardiogenic shock. T hese studies have reported improved circulatory support, an increase in systemic vascular resistance, and reduction in vasopressor use which ultimately may result in lower cardiac oxygen consumption.  The preliminary results suggest that mild therapeutic hypothermia could be a therapeutic option in hemodynamically unstable patients independent of current recommendations which support its use in cardiac arrest survivors. References Mild therapeutic hypothermia in cardiogenic shock syndrome. Zobel, Carsten MD; Adler, Christoph MS; Kranz, Anna MS; Seck, Catherine MD; Pfister, Roman MD; Hellmich, Martin MD; Kochanek, Matthias MD; Reuter, Hannes MD Critical Care Medicine . 40(6):1715–1723, June 2012.

Central lines terminating in the superior vena cava (i.e. internal jugular and subclavian placement) can also be used to determine the central venous oxygenation (Scv O 2 ), as part of the EGDT protocol.   An Scv O 2 of less than 70% would be an indicator that oxygen delivery to tissues is not matching the demand, and that further interventions are needed such as   1) Intubation to increase PaO 2 ,   2) Blood transfusion to achieve a Hct of ≥ 30%, 3) Initiation of an inotrope, usually Dobutamine.   While S cv O 2 was shown to correlate with mixed venous oxygenation Sv O 2 obtained from a pulmonary artery catheter, peripheral venous blood gases (VBG) are not good indicators of systemic oxygen extraction. Lactic acid has recently gained interest as a possible substitute for Scv O 2 to determine adequate delivery of oxygen to tissues. A study by Jones et al has shown that a lactic acid clearance of more than 10% at least ...

CHADS2 is a widely used model for estimating stroke risk in AF.  It estimates stroke risk in non-rheumatic AF by assigning 1 point each for C ongestive heart failure, H ypertension, A ge ≥ 75 years, or D iabetes mellitus and 2 points for history of S troke or TIA. For example, an 82-year-old (+1) patient with hypertension (+1) and past stroke (+2) would have a CHADS2 score of 4. Patients are considered to be at low risk with a score of 0 intermediate risk with a score of 1 or 2 and at high risk with a score 3 or more.  Of note, a past history of cerebral ischemia without other risk factors gives only 2 points (intermediate risk), yet most experts consider these patients to be at high risk. The majority of these patients, however, have some other risk factor and a score of at least 3.

Did you know the literature describing the cross-reactivity between cephalosporins and penicillins is 30-40 years old? It sort of takes the "modern" out of "modern medicine." At any rate, this is a literature review that aims to update the classical teaching that cross-reactivity between cephalosporins and PCN is ~10%. They identified 406 articles on the topic and distilled it down to 27 respectable articles for inclusion in summary. They rate the quality of the articles, and, unfortunately, find only a few good or outstanding articles and a preponderance of adequate evidence. But, essentially, what they find is the cross-reactivity boils down to the presence of a shared R1 side chain present on first-generation and some second-generation cephalosporins.     Specific first-generation cephalosporins, such as cefadroxil (Duracef), were seen to have up to 28% cross-reactivity in some series, though the typical rate was lower, down to 0....

Sympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units.   It occurs due to uncontrolled sympathetic surge with a diminish or unmatch parasympathetic response. According to Baguley criteria 5 out of the 7 clinical features should be present - tachycardia, tachypnea, hyperthermia, hypertension, dystonia, posturing, and diaphoresis. Various agents have been used for treatment like clonidine and Benzos   (article below) but haloperidol may worsen the symptoms. Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004. Please Click below to Read more about PAID.. Click Here

We are back...   We are happy to reconnect again with  anesthesia residents...and all who works in anesthesia... New Topics..New Guidelines...and updates in anesthesia... Just Stay Tuned

This is from Anesthesiology in August 2006, but still important. click here Ruppen et al. present a meta-analysis of well over one million parturients describing the incidence of serious neurologic injuries, including infection, after epidural analgesia and anesthesia. 1.37 million women are included in this risk analysis. This is the largest study to date on these complications. An associated editorial comments on the importance of risk factors, and standards of care including full sterile precautions and allowing adequate time for antiseptics to work ( 2 minutes is quoted) The Key findings are Epidural haematoma 1 in 168,000 Deep epidural infection, 1 in 145,000 Persistent neurologic injury, 1 in 240,000 Transient neurologic injury, 1 in 6,700

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients     Introduction In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters . Method We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications ...

You are called for preoperative clearance of a patient who has taken 20 mg of prednisone daily for 2 weeks. Should you be concerned about HPA axis suppression? How long does it take prednisone to suppress the HPA axis? Many sources cite that 3 weeks of daily therapy (of ≥20 mg) is needed to cause clinical blunting of the HPA axis. But the evidence base for this practice is unclear. Below we present 2 small studies of chemical – but not necessarily clinical – HPA suppression. In a small study of 10 healthy patients, Carella et al. found no HPA suppression 1 week after completing a 1 week course of prednisone (40 mg/three times daily for 3 days, then tapered over the next 4 days). In a small study of 9 COPD patients treated with 2 weeks of steroids, Schuetz et al. found HPA suppression up to 21 days after completing the course (40 mg of methylprednisolone, followed by an oral 13-day regime of 40 mg prednisone). Schuetz P, Christ-Crain M, Schild U, et al. Effect of a 1...