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Bleeding continues to be the Achilles heel of systemic anticoagulation, whether the agent used is warfarin or any of the new anticoagulants entering the market. Predictive models for bleeding include the following: HAS-BLED   (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol) HEMORR2HAGES  (hepatic or renal disease, ethanol abuse, malignancy, elderly, reduced platelet count or function, rebleeding, hypertension, anemia, genetic factors, excessive fall risk, stroke)   HAS-BLED beat two other scoring systems in a comparative analysis of trial data.

The third universal definition for myocardial infarction has been issued by the American College of Cardiology, American Heart Association, European Society of Cardiology, and World Heart Federation. It establishes the level of troponin necessary to diagnose MI in various clinical situations (e.g., after cardiac and noncardiac procedures). According to the definition, an MI diagnosis requires a cardiac troponin (I or T) level above the 99th percentile of a normal reference population, plus one or more of the following: symptoms of ischemia; new significant ST/T wave changes or left bundle branch block; pathologic Q waves on ECG; new loss of viable myocardium or regional wall motion abnormality, as observed on imaging; intracoronary thrombus diagnosed by angiography or autopsy.                         CLICK here to GET PDF article

Diuretics (furosemide/mannitol) While use of diuretics may improve urine output in the setting of acute kidney injury, again there is no evidence to support that they confer any improvement in outcomes measured (including need for RRT and mortality) . Furthermore, use of furosemide has been shown to be not only ineffective but also detrimental, associated with higher postoperative serum creatinine levels in cardiac patients . Of note, mannitol is often added to the priming solution used in CPB surgery. Although initially shown to confer some preventive benefits in children undergoing CPB surgery, these results have not been reproduced in repeat studies, with a suggestion that mannitol is actually associated with increased tubular injury when given in combination with dopamine . Theophylline Theophylline, an adenosine antagonist, in theory is proposed to preserve renal blood flow by attenuating vasoconstriction of renal vessels . Several small studies...

Difficult to Bag (BONES) Beard Obesity No Teeth Elderly (>55) Snores Difficult to Intubate   (LEMON) Look at head and neck Evaluate 3-3-2 Mallampati (Using Samsoon and Young mod, which added class IV, 1987) Obstruction=hot potato voice, can’t handle secretions, and Stridor (if audible=90% obstruction) Neck Mobility Difficult Extraglottic Device (RODS) Restricted Mouth Opening Obstruction: at or below the level of the larynx Disrupted or distorted airway. If the seat or seal of the device is disrupted Stiff lungs or cervical spine. Poor lung compliance or inability to extend neck may hamper seal   Difficult Cricothyrotomy (SHORT) Surgery/Disrupted Airway Hematoma Obese/Access Problems (Can’t get to neck) Radiation Tumor Difficult Physiology (HOP) Hypotension – either preintubation or the potential for intubation to cause it Oxygenation – either already satting poorly or the patient has minimal reserve pH -Ventila...

There have been few studies comparing the midline and paramedian approach on block success.  In cadavers, using epiduroscopy, paramedian catheters were observed to cause less epidural tenting, and pass cephalad more reliably than midline catheters. In patients, faster catheter insertion times were reported in the paramedian, and higher incidence of paraesthesia in the midline group. Adequate local infiltration is a prerequisite for patient comfort during paramedian puncture. The paramedian approach may be less dependent upon spine flexion. The risk of vascular puncture during epidural catheter placement was not associated with lumbar midline or paramedian technique in parturients, while another study suggested more paraesthesia and bloody puncture in non-pregnant adults when the midline approach was used. 1-Blomberg RG. Technical advantages of the paramedian approach for lumbar epidural pun...

Unexpected refractory hypotension under general anesthesia is an increasingly recognized perioperative issue.  One cause for this type of hypotension is vasoplegic syndrome (VS). It is most commonly seen during cardiac surgery, but can occur during any anesthetic.  It is characterized by severe hypotension refractory to catecholamine therapy in the absence of other identifiable causes for hypotension. While there is no standardized definition for VS, some researchers have defined it as a mean arterial pressure <50mmHg with a cardiac index >2.5 L/min x m2 and a low systemic vascular resistance despite adrenergic vasopressor administration. The incidence of VS in cardiac surgical patients is 8% to 10 %, but may increase to upwards of 50% of patients taking renin angiotensin system (RAS) antagonists.2  In cardiac surgical patients with persistent hypotension into the posto...

Ventricular arrhythmias and cardiac arrest have been reported with the use  of bupivacaine and patients with L-  carnitine deficiency. These complications occurred with blood levels  of bupivacaine that were not in the  toxic range. In experimental animals  this susceptibility was reversed with  supplementation of L- carnitine.  References 1. Wong GK, Crawford MW. Carnitine deficiency increases susceptibility to bupivacaine-induced cardiotoxicity in rats. Anesthesiology 2011; 114: 1417-24 2. Weinberg GL, Palmer JW, VadeBoncouer TR et al. Bupivacaine inhibits acylcarnitine exchange in cardiac mitochondria. Anesthesiology 2000; 92:523-8

As any 38- weeker 7 cm dilated with contractions q4min can tell you….epidurals rock. What hasn’t been as obvious in clinical practice and in the literature, is their effects in the general surgical population. The blunting of the sympathetic response, opiod -sparing effect and earlier return of bowel function have been well documented. An article in Anesthesiology provides an interesting observation about the slinky plastic catheter: From Anesthesiology : Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence: A Retrospective Analysis We evaluated cancer recurrence in men undergoing radical prostatectomy . After adjustment for confounding factors, patients who received general anesthesia combined with epidural analgesia had a 57% (95% CI, 17-78%) lower risk of cancer recurrence than patients who had general anesthesia and postoperative opioids . A propensity-matched analysis on a subset of the data gave a similar result: Epidural analgesia ha...

A nice example of a difference between elective anaesthesia and critical care practice when it comes to airway management is the selection of appropriate tracheal tube size when intubating, which is highlighted in a recent  Anaesthesia  article. In recent years progressively smaller tubes have been used in anaesthesia in pursuit of decreased tracheal injury, sore throat, and hoarseness and increased ease of placement. Patients likely to remain intubated for some time due to critical illness, however, may benefit from larger diameter tubes for the following reasons: Accumulation of biofilm debris, which increases with duration of intubation – this can significantly decrease the luminal internal diameter, but is less likely to be significant with larger tubes. Work of breathing during weaning: spontaneous breathing trials prior to extubation require patients to breathe through tracheal tubes. Volunteer studies have demonstrated that work of breathing increases as t...

Surgeon Anthony Atala demonstrates an early-stage experiment that could someday solve the organ-donor problem: a 3D printer that uses living cells to output a transplantable kidney. Follow the link to watch the  lecture                                                                                    Watch-click here

The Assessment of Blood Consumption tool is simple, and it turns out to be quite predictive.  Here’s how it works. Assess 1 point for each of the following: Heart rate > 120 Systolic blood pressure < 90 FAST positive Penetrating mechanism A score >=2 is predictive of massive transfusion. and to initiate the PRBCs:Plsama:Platelets 1:1:1 ratio  In this small series, the sensitivity of ABC was 89% and the specificity was 85%. The overtriage rate was only 13%. The investigators were satisfied enough with this tool that it is now being used to activate the massive transfusion protocol at the Mayo Clinic. Bottom line: ABC is a simple, easy to use and accurate system for activating your massive transfusion protocol, with a low under- and over-triage rate. Reference: Comparison of massive blood transfusion predictive models: ABC, easy as 1,2,3. Presented at the EAST 24th Annual Scientific Assembly, January 26, 2011, Session I P...

Cerebral Blood volume (CBV)–PaCO2 curve is   flatter than  CBF-PaCO2.. (0.014 mL/100g/mm Hg)  See the foto Hence decreasing PaCO2 from 40 to 20 mm Hg will will decrease CBV to 2.8 mL/100g (a 28% change). This translates into a 10–14 mL fall in whole-brain volume. This look  as small number .... but in the light of Pressure Volume index  it will not be considered as small?? Shapiro et al. showed that the amount of fluid that must be rapidly injected into or withdrawn from the  intracranial space to change ICP tenfold (e.g., from 10 to 100 mm Hg) is normally ≈26 mL. This is called the pressure-volume index (PVI). However, PVI values in patients with mass lesions or closed head injuries may be as low as 5 mL. In such situations, a change in CBV of 10–15 mL would be enormous, and it is not surprising that hyperventilation has come to occupy such ...

  Tramadol lands squarely in the gap between oral analgesics used for "no pain" – ibuprofen, acetaminophen – and analgesics used for "real pain" – hydrocodone derivatives.  The literature describing the analgesic properties of tramadol is bizarre, with multiple comparisons with placebo, nerve blocks, adjunctive epidural anesthesia, etc., and very few head-to-head comparisons to the sorts of medications we routinely use. When there are comparative efficacy reports, they typically conclude that tramadol is effective...just as effective as the NSAIDs its being compared with. The theory  when considering use of tramadol is that it has a better safety profile than hydrocodone and is less dependence-forming. These claims may be true, but not  true to the extent that it is clinically relevant. Tramadol still generates an opioid withdrawal syndrome and, as this article describes, overdose/abuse still results in apnea with need for ventilatory support. Ad...

1- Preoperative Factors  (Kehlet et al. Persistent Pain After Breast Cancer Treatment: A Critical Review of Risk Factors and Strategies for Prevention. The Journal of Pain, Vol  12, No 7 (July), 2011: pp 725-746) • Young  age : Aggressive nature of the tumor, ↑ rate of recurrence • Obesity :  C hallenging axillary dissection  (more fatty tissue) • Ethnicity and psychological factors • Preop pain in the breast and/or in other locations : Indicate a state of higher pain sensitivity • G enetics : Susceptibility to chronic pain following nerve injury is genetically affected by   CACNG2  (Genome Res, 2010) 2-Intraoperative factors Mastectomy vs breast conservative Surgery :  No conclusive results in favor of one of these surgeries. Importance of   the association with radiotherapy Axillary lymph node dissection vs Sentinel lymph node biopsy :  More pain in ALND due to surgical damage to ICBN.   Bre...

Continuous oxygen therapy (COT) has become widely accepted in the last 20 years in patients with continuous hypoxemia. COT has been shown to significantly improve survival in hypoxemic patients with chronic obstructive pulmonary disease (COPD). The benefits of oxygen therapy are best established for patients with severe disease associated with resting hypoxemia. . The Medical Research Council examined the impact of at least 15 hours per day of oxygen in 87 COPD subjects with a resting PaO2 between 40 to 60 mmHg in the stable state.  Survival was better with oxygen utilization compared to no oxygen. COT has been shown to reduce hospitalizations and lengths of stay. The mechanisms for this improved survival remain elusive. Limited data suggest that LTOT may ameliorate pulmonary vasculopathy, at least during intermediate follow-up. The role of oxygen therapy in COPD patients experiencing nocturnal desaturation also remains controversial.  A m...

Hypoxemia if present in Opioids overdose has three differential diagnosis: 1-All of us know this differential ,HYPOVENTILATION 2-Another explanation is Pulmonary edema.    Hypothetical mechanisms for pulmonary edema in opioid overdose include negative pressure pulmonary edema from inspiring against a closed (collapsed) glottis. 3-  A cute lung injury that is thought to occur in patients who are given reversal agents, in whom sudden sympathetic overactivity results in capillary leak in the lungs. So next time you have hypoxemia in opioid overdosed patient,dont forget to listen to the lungs and to order X-ray to rule out any edema....

When using Pediatric bougie there is  concern about tracheal rupture and used when ETT size >3 mm. To avoid bleeding from large adenoids, do not place nasal airway in child <1 yr of age Always during  transport  apply cervical collar in child with ETT, even if just moving from one bed to another,  to avoid displacement of ETT  Cuffed ETTs —now considered beneficial due to lower pressures. Children highly dependent on diaphragm; once airway secured, insert nasogastric tube (NGT) or orogastric tube (OGT) as soon as possible to decompress stomach (NGT or OGT should be twice ETT size)  Proper bag-valve mask (BVM) technique — if attempting to use BVM on child with low O2 saturation, first action to place oral airway. straight blade 0 used only in just-born newborn or premature infant, otherwise straight blade 1 used and shift to blade 2 at 2(years).. 2 times ETT size for NGT, OGT, and Foley catheter 3 times ETT size for tube...