Sugammadex binds and inactivates the aminosteroid nondepolarizing muscle relaxants rocuronium and vecuronium. Sugammadex is available in 50 countries, but the United States is not one of them. The US Food and Drug Administration turned down approval for the drug in 2008 because it sought more information concerning allergic reactions and bleeding events. Approval was also denied in the 3rd quarter last year due to concerns about a hypersensitivity study. Hopefully sugammadex will be available here soon. In clinical situations, three drugs have been shown to displace rocuronium from sugammadex: toremifene, a selective estrogen receptor modulator used to treat patients with breast cancer, fusidic acid, an antibiotic that inhibits translocation during protein synthesis, and flucloxacillin, an antibiotic analog of cloxacillin. None of these are commonly used in anesthesia or postoperative care, and so it seems unlikely that this could be an important clinical problem...
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Valvular disease : Among the valvular affections the most dangerous one is aortic stenosis, unfortunately, this kind of disease is the commonest one in current surgery population. In case of severe aortic stenosis (valvular area \ 1 cm or 0.6 cm 2 /m 2 BSA) clinical condition of patient should be evaluated: symptomatic patients undergoing elective surgery should be offered chance of prophylactic aortic valve replacement prior to non-cardiac surgery. Patients who refuse or are not eligible should be considered for a percutaneous valve implantation or at least balloon aortic valvuloplasty. This strategy should be considered even in case of asymptomatic patients scheduled for high-risk surgery. Asymptomatic patients scheduled for intermediate or low-risk surgery can be treated in a conservative manner. High-risk surgery can be performed only in patients not eligible for aortic replacement only if really needed and under strict hemodynamic monitoring. Mi...
You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach. In order to avoid the blank stare when asked "what size"? Here's a nice mneumonic about Pediatric "tube" sizes... easy as 1-2-3-4!!! Please note ETT = endotracheal tube size. 1 x ETT = (age/4) + 4 (formula for uncuffed tubes) 2 x ETT = NG/ OG/ foley size 3 x ETT = depth of ETT insertion 4 x ETT = chest tube size (max, e.g. hemothorax) So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT). Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5
A) Hemoglobin A1c is 7.0% and 6.8% on repeat testing. DM is confirmed because two A1c tests are positive. B) Hemoglobin A1c is 7.0% and 6.8% on repeat testing but fasting plasma glucose is 124 mg/dL. Despite the fasting plasma glucose < 126 mg/dL, DM is confirmed because two A1c tests are positive. C) Fasting plasma glucose is 127 mg/dL and on repeat testing is 128 mg/dL, but hemoglobin A1c is 6.4%. Despite the HbA1c < 6.5%, DM is confirmed because two FPG tests are positive. D) Hemoglobin A1c is 7.0% and fasting plasma glucose is 126 mg/dL. DM is confirmed - 2 independent tests are positive. E) Hemoglobin A1c is 7.0% and fasting plasma glucose is 124 mg/dL. A confirmatory A1c or FPG is needed.
The proliferation of monitors in anaesthesia is obvious. The goal of monitoring as an adjunct to clinical decision making is to directly reduce the incidence of complications. This is based on the premise that unambiguous and accurate information, which is readily interpretable and available, will help the anaesthesiologist in choosing and initiating correct therapeutic interventions. The unanswered question is whether the individual anaesthesiologist's performance—the human factor—is perhaps far more important than implementing new monitoring equipment or other new safety initiatives in a situation in which we wish to reduce the rate of postoperative complications. However, we do not know whether pulse oximetry might protect against the human factor when that factor is negligent. Pulse oximetry monitoring substantially reduced the extent of perioperative hypoxaemia, enabled the detection and treatment of hypoxaemia and related respiratory events and promoted several changes in pat...
β-blockers are contraindicated to treat a hyperten sive crisis from phenylephrine (such as an accidental over dose). β-blockers in this situation can reduce myocardial contractility and produce acute pulmonary edema in the face of high afterload. Groudine SB, Hollinger I, Jones J, DeBouno BA. New York State guidelines on the topical use of phenylephrine in the operating room: the Phenylephrine Advisory Committee. Anesthesiology. 2000;92: 859-864.
Siphon test The catheter is held upright and a fluid level sought. If the catheter is then elevated, the fluid level should fall (see inset) as the fluid siphons in to the epidural space, which is usually under negative pressure compared with atmospheric. If the fluid column continues to rise, this may suggest subarachnoid placement. The siphon test can be reassuring, but is not mandatory. Aspiration This should be considered mandatory. The Luer connector is attached to the catheter and a syringe is used to apply negative pressure. Free and continued aspiration of clear fluid can indicate subarachnoid placement of the catheter. However, if saline has been used for loss of resistance, it is not unusual for a small amount of this to be aspirated. If there is doubt, the aspirated fluid can be tested for glucose (cerebrospinal fluid will generally test positive) or mixed with thiopentone (cerebrospinal fluid forms a precipitate). If blood is freely and continuously aspirated, this sug...
DVT (%) PE (%) Level of Risk Calf Proximal Clinical Fatal Successful Prevention Strategies Low risk: Minor surgery in patients <40 yr with no additional risk factors 2 0.4 0.2 <0.01 No specific prophylaxis; early and aggressive mobilization Moderate risk: Minor surgery in patients with additional risk factors; surgery in patients 40-60 yr with no additional risk factors 10-20 2-4 1-2 0.1-0.4 LDUH q12h, LMWH <3400 U daily, GCS, or IPC High risk: Surgery in patients >60 yr, or 40-60 yr with additional risk factors (prior VTE, cancer, molecular hypercoagulability) 20-40 4-8 2-4 0.4-1.0 LDUH q8h, LMWH >3400 U daily, or IPC Highest risk: Surgery in patients with multiple risk factors (age >40 yr, cancer, prior VTE); hip or knee arthroplasty, HFS; major trauma; SCI 40-80 10-20 4-10 0.2-5 LMWH (>3400 U daily), fondaparinux, oral VKAs (INR, 2-3), or IPC or GCS + LDUH or LMWH DVT, deep venous thrombosis; GCS, graduated compression stockings; HFS, hip-fracture surgery; INR, ...
In spinal anesthesia in patients with pulmonary disease, it is best to keep the level below T8 to avoid the accessory muscle blockade.
Safety Issues Very low therapeutic index drugs Severe consequences to “under” or “over” dosing Necessity to adjust the level of drug effect frequently Efficiency Issues Necessity to produce onset of drug effect quickly Necessity to produce offset of drug effect quickly
Most capillary beds contain fenestrations between endothelial cells that are approximately 65 Ã…ngstroms in diameter. In the brain, with the exception of the choroid plexus, pituitary, and area postrema, tight junctions reduce this pore size to approximately 8 Ã…ngstroms. As a result, large molecules and most ions (including pharmacologic agents with these characteristics) are prevented from entering the brain’s inter stitium or from passing between the plasma and CSF.