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An odourless inhalational anaesthetic has the following properties: oil: gas partition coefficient = 1.9 blood:gas partition coefficient = 0.14 MAC = 71% boiling point = -108 °C It is non-irritant to the airway and is not metabolised. Which of the following is most likely to be true of this agent? A - More likely to produce hepatotoxicity than desflurane B - Less volatile than desflurane C - Potency greater than isoflurane D - Slower offset than sevoflurane E - Speed of onset faster than nitrous oxide write down your answers in the comment area..or send the answer on the BLOG email....... From now till 6 month...those with highest correct answers will be awarded...

Some high-yield, interesting points in the management of ICH. Myocardial “stunning” with depressed ejection fraction and pulmonary edema should be expected, due to a form of tako-tsubo cardiomyopathy, most commonly in subarachnoid hemorrhage. It’s not due to ischemia and gets better over weeks. Fever reduction  is recommended, although therapeutic cooling and targeted temperature management (induced hypothermia) have not been shown prospectively to improve outcomes. The increased metabolic demand of shivering caused by cooling concerns some experts. Vasospasm  after subarachnoid hemorrhage is common, predictable and can cause cerebral infarction if untreated. Thick blood in the subarachnoid space and bleeding in the lateral ventricles bilaterally signals higher risk for vasospasm.  Nimodipine  selectively vasodilates cerebral arteries and improves outcomes and should be given to all victims of SAH due to a ruptured aneurysm. A phase III study of pravastatin...

4 types of chronic neuropathic pain following breast cancer surgery due to surgical trauma : Jung BF et al. - Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain 2003;104:1-13 1-Intercostobrachial neuralgia ++ : post mastectomy pain syndrome consists of pain and sensory changes localized to the distribustion of the ICBN - the axilla, medial upper arm, and/or the anterior chest wall on the ipsilateral side of the surgery.   Fabro et al. Post-mastectomy pain syndrome: Incidence and risks . The Breast   2012,  321-325 . 2-Pain secondary to the presence of a neuroma : Neuroma is formed from masses of tangled axons formed at the end of severed peripheral nerves trapped in scar tissue. 3-Phantom breast pain : sensory experience of a removed breast that is still present and is painful 4-Other nerve injury pain : may result from damage or traction to the medial and lateral pectoral, long thoracic (pain at rest...

Instructional video detailing the use of thoracic ultrasound in the  evaluation of pneumothorax. Very Nice one ..                                                               Click Here

      A comparison of the analgesic efficacy and side effects of paravertebral vs epidural blockade for thoracotomy  • Analgesia                PVB = Epidural •Pulmon Complic   PVB < Epidural •failure                    PVB < Epidural •Hypotension          PVB < Epidural •PONV                   PVB < Epidural •Urinary retention   PVB < Epidural Davis et al Br J Anaesth 2006

chronic postoperative pain    commonly associated with thoracotomy, hernia repair, pyloromyotomy, and amputation. Prevalence after thoracotomy 57% at 7 to 12 mo (decreases over time, but 21% of patients report persistent pain after 6-7 yr) Risk after inguinal herniorrhaphy  ≈ 12% (possibly less with laparoscopy); cutaneous sensory abnormalities do not correlate with severity of nerve damage Children diagnosed with pyloric stenosis in infancy had 4-fold greater risk of reporting chronic abdominal pain several years later, compared to controls (may be associated with gastric suctioning) Amputation: acute phantom limb pain best predictor of chronic phantom limb pain at 6 mo and 1 yr; preamputation pain best predictor of chronic phantom limb pain at 2 yr; acute residual limb pain good predictor of chronic residual limb pain

  Cytochrome P450 variants The cytochrome P to be metabolised by more than one sub-type of enzyme, but clinically important reductions in metabolism will be seen if there are reductions in the activity of an enzyme that normally predominates in the metabolism of the drug. Those polymorphisms that produce an increase in enzyme activity are associated with rapid drug clearance and inadequate therapeutic effect. 450 group of enzymes are responsible for the great majority of microsomal phase I oxidation reactions. Four classes of cytochrome P450 enzymes (CYP1-4) each with several sub-groups have been identified. Polymorphisms in at least four cytochrome P450 enzymes have been found that are associated with increased, reduced or even absent enzyme activity. Most drugs have the potential to be metabolised by more than one sub-type of enzyme, but clinically important reductions in metabolism will be seen if there are reductions in the activity of an enzyme that normally predominates i...

Different formulas have been  developed using body weight to calculate the distance (D) from the skin to the lumbar  epidural space: Depth(mm) = (weight in kg + 10) x 0.8 For example, in a 20-kg child the Depth would be calculated as follows: (20 + 10) 0.8 (30) 0.8 = 24 mm or  2.4 cm distance to the epidural space.  An alternative simpler  approximation is Depth (mm) = 1 mm/kg body weight. So in the 20-kg child D would be  20 mm or 2 cm Suresh S, Wheeler M. Practical pediatric regional anesthesia.  Anesthesiol Clin  North Am 2002;20(1):83–11 3.

Dr. Kheir was involved in an incident with a critically ill 9 month old patient who sustained brain injury after prolonged hypoxemia. She was put on bypass, but it was too late to save her brain. After that, Kheir started dreaming of a syringe with intravenous oxygen they could’ve given her. And went to work on it. hey now seem to have a working prototype of a lipid emulsion that contains oxygen and can be injected into the blood stream, release the oxygen and thereby reoxygenate the blood. Their findings are published in  Science Translational Medicine.  Actually we have only the Abstract to this article.. Intravenous Oxygen Intravenous administration of oxygen was tried in the early 1900s, but these attempts failed to oxygenate the blood and often caused dangerous gas embolisms as free oxygen oxygen in blood spontaneously formed larger gas bubbles. Dr Kheir and his Harvard Team has engineered around this problem by packaging the gas into small, deformable ...

Two recently presented abstracts at the 2012 Society of Critical Care Medicine conference suggest that the combination of vancomycin and piperacillin-tazobactam may lead to acute kidney injury (AKI) in the critically ill. There may also be evidence to suggest that piperacillin-tazobactam alone increases the risk of AKI. Both abstracts retrospectively compared patients who received either vancomycin alone or the combination of vancomycin and piperacillin-tazobactam. In both studies, the rates of AKI were significantly lower in patients treated with vancomycin alone as compared to patients receiving both vancomycin and piperacillin-tazobactam. Bottom line: Although the current evidence does not support a change in our clinical practice, more prospective studies exploring this topic are necessary. Min, et al.  Acute Kidney Injury in Patients Recieving Concomitant Vancomycin and Piperacillin/Tazobactam . Critical Care Medicine. December 2011. 39(12); p 200 Hellwig, ...

Is acetaminophen responsible for the worldwide rise in childhood asthma over the past 30 years? Citing a mounting pile of circumstantial evidence from epidemiologic observational studies,  John McBride  of  Akron’s Children’s Hospital in Ohio  believes so, and that it’s time to officially push the worry button. The theory is that the fear of aspirin-induced Reye’s syndrome in the 1980s resulted in a large increase in the amount of acetaminophen prescribed to children, causing the observed spike in asthma incidence we’ve seen since then. How? Acetaminophen depletes glutathione, an antioxidant peptide that can curb inflammation in the airways. This hypothetical etiology was proposed by  Varner back in 1998 , and McBride reiterated it in his  review in the November  Pediatrics ,  in which he argues the acetaminophen-asthma link is now strong enough that doctors should counsel the parents of children with asthma (or at risk for as...

Remember that weird advice we were taught as physicians-in-training to give to smoking patients before an upcoming surgery? “You should quit smoking, but not within the 2 weeks just before your surgery.” (It sounds off-key to me even as I write it now.) Based on … what? Some medical lore passed down from a decades-old study none of us ever actually read? I always thought that counsel sounded fishy. Apparently, according to a few smart people who looked at the actual evidence, it was. In a literature review and meta-analysis (actually 3 meta-analyses),  Myers et al  examined 9 studies and found  no evidence of increased complications (pulmonary or otherwise) associated with quitting smoking within 8 weeks before surgery of any kind.  They include, and debunk, the  1989 cohort study  that birthed the dogma that just-quit smokers are at increased risk for post-op pulmonary complications. That paper in fact did not show a statistically significan...

Maybe it’s the surgeons who are tired of consulting us for “vent management,” and finding out we can’t get patients off the vent any faster than they can without our help. Anyway, some troublemakers in Germany (Dirk Schadler et al) found that among 300 patients in surgical intensive care units (SICUs), an automatically-weaning ventilator was as good as human beings using a ventilator weaning protocol at liberating patients from mechanical ventilation. What They Did Authors randomized  300 post-surgical patients at 3 SICUs  at one hospital in Kiel, Germany after they had been on  9 hours of mechanical ventilation  to one of two weaning strategies. Half were managed with standard ventilator-weaning protocols, managed by physicians and respiratory therapists. Half had a switch on their ventilators (Evita XL) flipped to enable the SmartCare software embedded into it. This software automatically adjusts the pressure support delivered in response to patient ef...

Effect of Volatile Anesthetics on Systemic and Alveolar Inflammatory Response  Schilling T, et al. Anesthesiology 2011;115:65 Design: 63 patients for thoracotomy 21-propofol (4mg/kg/hr) 21- Desflurane (1MAC) 21- Sevoflurane (1MAC) OLV at 7ml/kg PEEP=5 BAL TNF before and after OLV Findings: Desflurane & Sevoflurane attenuate proinflammatory changes even  w ith protective OLV compared to Propofol

                                                  PRESS on the photo for clearer details

VAP is defined as pneumonia that occurs more than 48 to 72 hours after endotracheal intubation.     Although the incidence of VAP is poorly defined, an estimated 9 to 27% of all intubated patients develop VAP.   The estimated risk of VAP is  3% per day during the first 5 days of ventilation,  2% per day during days 5 to 10, a and 1% per day thereafter. 2004 American Thoracic Society - Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.  Am. J. Respir. Crit. Care Med . 2005;171(4):388-416. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15699079 [Accessed June 3, 2009].

We think of pain as a symptom, but there are cases where the nervous system develops feedback loops and pain becomes a terrifying disease in itself. Starting with the story of a girl whose sprained wrist turned into a nightmare, Elliot Krane talks about the complex mystery of chronic pain, and reviews the facts we're just learning about how it works and how to treat it.                                                                                                                                               Click Here

The radial artery is occasionally used as a conduit for bypass surgery, and its patency lasts longer in comparison to the saphenous veins.  Prior to heart bypass surgery, Allen's test is performed to assess the suitability of the radial artery to be used as a conduit.  A result of less than 3 seconds is considered as good and suitable. A result of between 3-5 seconds is equivocal, whereas the radial artery will not be considered for grafting if the result is longer than 6 seconds . Is the Allen test reliable enough?  -  Eur J Cardiothorac Surg  (2007)  32  (6):  902-905.

The machine components can also be logically conceptualized by the amount of pneumatic pressure they are exposed to: The  High-pressure circuit  consists of those parts which receive gas at cylinder pressure hanger yoke (including filter and unidirectional valve) yoke block cylinder pressure gauge cylinder pressure regulators The  Intermediate pressure circuit  receives gases at low, relatively constant pressures (37-55 psi, which is pipeline pressure, or the pressure downstream of a cylinder regulator) pipeline inlets and pressure gauges ventilator power inlet Oxygen pressure-failure device (fail-safe) and alarm flowmeter valves oxygen and nitrous oxide second-stage regulators oxygen flush valve The  Low-pressure circuit  includes components distal to the flowmeter needle valves flowmeter tubes vaporizers check valves (if present) common gas outlet

For patients presenting to the ED with chest pain, we've been taught that “classic” or “typical” presentations for ACS (chest pressure with radiation to the left neck/jaw/shoulder/arm, dyspnea, diaphoresis, nausea, vomiting, lightheadedness) are most worrisome. Yet, many of the patients that present with typical symptoms end up having negative workups for ACS. What are the symptoms that truly predict ACS? Three major studies have demonstrated that the best predictors of ACS in patients presenting to the ED with chest pain are (not necessarily ranked in order): 1. chest pain that radiates to the arms, especially if the pain radiates bilaterally or to the right arm 2. chest pain associated with diaphoresis 3. chest pain associated with vomiting 4. chest pain associated with exertion The description of the chest pain (e.g. "pressure" or "squeezing," etc.), the dyspnea, nausea, lightheadedness, and pain at rest were, surprisingly, not helpful at predi...

Pharmacogenetic variation has been identified in drug metabolism (acetylation, cytochrome P450 variants, plasma cholinesterase variants), inability to compensate for drug effects (G6PD, acute porphyrias) and in drug effects themselves (malignant hyperthermia). Each of the examples will be discussed separately . Acetylator status Acetylation is one of the non-microsomal phase II conjugation reactions. The gene controlling the enzyme N-acetyltransferase, exists in one of two forms that determines the acetylator status of an individual which can be slow or fast. The prevalence of slow acetylation is 60% in Caucasians and 10-20% in Asians. Drugs subject to N-acetylation include isoniazid, hydralazine, procainamide, some sulphonamides, sulphasalazine, nitrazepam, and caffeine. Slow acetylators are at higher risk of side effects of these drugs such as peripheral neuropathy with isoniazid, lupus syndrome with hydralazine and procainamide, allergic reactions and hemolysis with sulphona...

Taking care of Drowning patient in ICU Treat drowning victims as ARDS patients, with low tidal-volume lung-protective mechanical ventilation. Not weaning mechanical ventilation for at least 24 hours, even if a drowning victim appears ready to extubate: the underlying pulmonary injury may result in recurrence of pulmonary edema, reintubation and increased risk of complications. Pneumonia is usually not present initially (12% in one series) and authors believe antibiotics may be over-prescribed and sometimes harmful; instead, use clinical evidence of infection or bronchoscopic / mini-BAL sampling to identify pneumonia and need for antibiotics. Swimming pool water in particular is unlikely to cause pneumonia. On the other hand, late-onset nosocomial pneumonias (i.e., ventilator-associated pneumonia) may be equally common among mechanically ventilated drowning victims as those with other causes of respiratory failure. Systemic inflammatory response syndrome (SIRS) can occur ...

Drowning is uncommon but by no means rare in the U.S.: it’s the second leading cause of death by injury in the U.S. among toddlers (3 per 100,000 among children aged 1 to 4), and you are  200 times more likely to die by drowning  during a boat ride as to die from trauma during a trip by automobile. Drowning kills about 500,000 people a year worldwide, according to the WHO. What happens? We can only hold our breath for about a minute. Eventually, a person submerged in water gasps for air, aspirates water, and starts coughing as a reflex response; continued aspiration follows. Hypoxemia leads to unconsciousness, apnea, and cardiac decompensation: tachycardia, then bradycardia, pulseless electrical activity (PEA), then asystole. From the last breath of air to final cardiac arrest, drowning may take less than a minute, to several minutes. Colder water (hypothermia) slows the entire process. Patient in ER... Recognize that only 6% of people rescued by lifeguar...

Mode Reservoir (breathing bag) Rebreathing Example Open No No Open drop Semi-open Yes No Nonrebreathing circuit, or Circle at high FGF (> V E ) Semi-closed Yes Yes, partial Circle at low FGF (< V E ) Closed Yes Yes, complete Circle (with pop-off valve [APL] closed)