The safest way of doing fibreoptic intubation is with the patient under conscious sedation and maintaining spontaneous respiration. Short acting and easily titrable analgesics are excellent choices for the intensely , but usually brief airway manipulation during fibreoptic nasotracheal intubation .This study was undertaken to evaluate the efficacy of propofol for conscious sedation for FOI and to compare it with a combination of fentanyl and midazolam which is frequently used for this purpose. The parameters studied were, the quality of sedation, intubating conditions, haemodynamic changes, degree of amnesia and global acceptance of the procedure under topical anaesthesia. In our study, we found that in the doses used by us, propofol produced comparable intubating conditions as a combination of midazolam and fentanyl. It produced significantly more sedation but difference between the two groups was significant only at 2 minutes (p value=0.028). Propofol leads to less increase in heart rate when the fiberscope was inserted endotracheally (P value=.007) .As the procedure progressed more boluses of propofol were needed to continue with the procedure. The degree of amnesia for the procedure was less with propofol however; the degree of global acceptance was comparable. To conclude propofol can be used for nasotracheal fibreoptic intubation, however its role in difficult airway and the dose required need more evaluation.
{"title":"Propofol for Conscious Sedation for Fibreoptic Nasotracheal Intubation: Comparison with Fentanyl - Midazolam Combination","authors":"K. Saxena","doi":"10.23880/ACCMJ-16000133","DOIUrl":"https://doi.org/10.23880/ACCMJ-16000133","url":null,"abstract":"The safest way of doing fibreoptic intubation is with the patient under conscious sedation and maintaining spontaneous respiration. Short acting and easily titrable analgesics are excellent choices for the intensely , but usually brief airway manipulation during fibreoptic nasotracheal intubation .This study was undertaken to evaluate the efficacy of propofol for conscious sedation for FOI and to compare it with a combination of fentanyl and midazolam which is frequently used for this purpose. The parameters studied were, the quality of sedation, intubating conditions, haemodynamic changes, degree of amnesia and global acceptance of the procedure under topical anaesthesia. In our study, we found that in the doses used by us, propofol produced comparable intubating conditions as a combination of midazolam and fentanyl. It produced significantly more sedation but difference between the two groups was significant only at 2 minutes (p value=0.028). Propofol leads to less increase in heart rate when the fiberscope was inserted endotracheally (P value=.007) .As the procedure progressed more boluses of propofol were needed to continue with the procedure. The degree of amnesia for the procedure was less with propofol however; the degree of global acceptance was comparable. To conclude propofol can be used for nasotracheal fibreoptic intubation, however its role in difficult airway and the dose required need more evaluation.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121506635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In the 1907s a dedicated group of physicians involved in the emergency care of children in North America, pioneered solutions regarding critically ill children. With that commitment, Paediatric Advanced Life Support (PALS) has evolved to be the benchmark for resuscitation training in paediatric clinical disciplines world-wide, The AHA’s PALS Course has been updated with new science [1]. Of equal relevance in resuscitation medicine, the European Resuscitation Council (ERC) has published guidelines for paediatric life support [2]. ERC acknowledges that flexibility is required in crisis management due to differences in infrastructure support. Paediatric anaesthesiologists will benefit from reviewing the different scenarios that endanger the safety of a child under their care.
{"title":"Paediatric Perioperative Life Support: Safety in the Fast Lane","authors":"L. Chan","doi":"10.23880/ACCMJ-16000136","DOIUrl":"https://doi.org/10.23880/ACCMJ-16000136","url":null,"abstract":"In the 1907s a dedicated group of physicians involved in the emergency care of children in North America, pioneered solutions regarding critically ill children. With that commitment, Paediatric Advanced Life Support (PALS) has evolved to be the benchmark for resuscitation training in paediatric clinical disciplines world-wide, The AHA’s PALS Course has been updated with new science [1]. Of equal relevance in resuscitation medicine, the European Resuscitation Council (ERC) has published guidelines for paediatric life support [2]. ERC acknowledges that flexibility is required in crisis management due to differences in infrastructure support. Paediatric anaesthesiologists will benefit from reviewing the different scenarios that endanger the safety of a child under their care.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122641290","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Practical Tips in Neuromodulation for Pain","authors":"D. Bendersky","doi":"10.23880/ACCMJ-16000134","DOIUrl":"https://doi.org/10.23880/ACCMJ-16000134","url":null,"abstract":"","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130774227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective: We aimed to analyze the clinical signs of left ventricular outflow tract obstruction and its management in the perioperative period of major non-mitral cardiovascular procedures. Design. Case series analysis. Methods and Results Thirteen (10 males, 3 females) patients aged 64 (56; 74) y.o. with acutely emerged left ventricular outflow tract obstruction during/after non-mitral cardiovascular procedure between May 2006 and May 2018 were included. Methods: The procedures were as follows: coronary artery bypass grafting – n=11, aortic valve replacement – n=1, abdominal aortic membrane resection (aortic dissection DeBakey type I, acute legs ischemia) – n=1. Left ventricular outflow tract obstruction with systolic anterior motion of anterior leaflet of mitral valve was detected in 0.9% of the total number of perioperative echocardiography examinations. Three variants of its clinical course were described: (1) intracardiac and systemic hemodynamics recovery with a specific therapy (most cases); (2) full resistance to therapy with sustainable systolic anterior motion persistence; (3) termination of systolic anterior motion as a result of the therapy, but the paradoxical persistence of low cardiac output syndrome. Conclusion: Practitioners’ vigilance and Echocardiographic monitoring are needed for early detection of acute left ventricular outflow tract obstruction. Its development can be a marker of the extremely hard concentric left ventricular hypertrophy as a cause of the low cardiac output syndrome.
{"title":"Acute Left Ventricular Outflow Tract Obstruction in Non - Mitral Cardiovascular Surgery: A Case Series Analysis","authors":"L. Krichevskiy","doi":"10.23880/ACCMJ-16000137","DOIUrl":"https://doi.org/10.23880/ACCMJ-16000137","url":null,"abstract":"Objective: We aimed to analyze the clinical signs of left ventricular outflow tract obstruction and its management in the perioperative period of major non-mitral cardiovascular procedures. Design. Case series analysis. Methods and Results Thirteen (10 males, 3 females) patients aged 64 (56; 74) y.o. with acutely emerged left ventricular outflow tract obstruction during/after non-mitral cardiovascular procedure between May 2006 and May 2018 were included. Methods: The procedures were as follows: coronary artery bypass grafting – n=11, aortic valve replacement – n=1, abdominal aortic membrane resection (aortic dissection DeBakey type I, acute legs ischemia) – n=1. Left ventricular outflow tract obstruction with systolic anterior motion of anterior leaflet of mitral valve was detected in 0.9% of the total number of perioperative echocardiography examinations. Three variants of its clinical course were described: (1) intracardiac and systemic hemodynamics recovery with a specific therapy (most cases); (2) full resistance to therapy with sustainable systolic anterior motion persistence; (3) termination of systolic anterior motion as a result of the therapy, but the paradoxical persistence of low cardiac output syndrome. Conclusion: Practitioners’ vigilance and Echocardiographic monitoring are needed for early detection of acute left ventricular outflow tract obstruction. Its development can be a marker of the extremely hard concentric left ventricular hypertrophy as a cause of the low cardiac output syndrome.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114894266","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"As A Clinical and Radiographic Syndrome Posterior Reversible Encephalopathy Syndrome (PRES)","authors":"A. Sonmezler","doi":"10.23880/accmj-16000160","DOIUrl":"https://doi.org/10.23880/accmj-16000160","url":null,"abstract":"","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"92 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121406671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nationally thousands of patients every year require endotracheal intubation after failure of non-invasive ventilation for a multitude of pathologies. These pathologies include but are not limited to chest infections, exacerbations of known lung disease, pancreatitis, neuromuscular diseases and acute respiratory distress syndrome (ARDS). Some of these patients may also be severely haemodynamically unstable and therefore intubation may be associated with a high risk of cardiovascular collapse despite the clinician’s best intentions. Patients that will require mechanical ventilation for a prolonged period or be slow to wean off mechanical ventilation can often be accurately predictable. We identified three patients and performed a percutaneous tracheostomy directly from NIV whilst bypassing endotracheal intubation. All 3 of these patients were severely haemodynamically unstable to the extent it was felt that all 3 may completely cardiovascular collapse in the induction or sedative period. However all 3 required invasive ventilation. The procedure was performed under ultrasound guidance, with local anaesthetic infiltration and under light sedation. We describe all three of these patients. The procedure was well tolerated in all 3 cases. Airway care and tracheal suctioning could start immediately after the procedure. As these patients never had to be sedated and ventilated for a prolonged period, no deconditioning occurred. A change to their pre-tracheostomy ventilator settings was not always necessary and weaning could begin promptly. By avoiding the typical 7-10 day period of intubation and deconditioning, it is approximated ITU stay could be cut by up to 7 days. This can have a significant economic impact in both ITU bed days as well as physical capacity. We devised a safety checklist to maintain safety during the procedure, advocating the use of ultrasound whilst remaining aware at all times of the potential urgent need for airway protection.
{"title":"Direct Percutaneous Tracheostomy from NIV in ICU Patients with Respiratory Failure - A Case Series","authors":"L. Rahman","doi":"10.23880/accmj-16000146","DOIUrl":"https://doi.org/10.23880/accmj-16000146","url":null,"abstract":"Nationally thousands of patients every year require endotracheal intubation after failure of non-invasive ventilation for a multitude of pathologies. These pathologies include but are not limited to chest infections, exacerbations of known lung disease, pancreatitis, neuromuscular diseases and acute respiratory distress syndrome (ARDS). Some of these patients may also be severely haemodynamically unstable and therefore intubation may be associated with a high risk of cardiovascular collapse despite the clinician’s best intentions. Patients that will require mechanical ventilation for a prolonged period or be slow to wean off mechanical ventilation can often be accurately predictable. We identified three patients and performed a percutaneous tracheostomy directly from NIV whilst bypassing endotracheal intubation. All 3 of these patients were severely haemodynamically unstable to the extent it was felt that all 3 may completely cardiovascular collapse in the induction or sedative period. However all 3 required invasive ventilation. The procedure was performed under ultrasound guidance, with local anaesthetic infiltration and under light sedation. We describe all three of these patients. The procedure was well tolerated in all 3 cases. Airway care and tracheal suctioning could start immediately after the procedure. As these patients never had to be sedated and ventilated for a prolonged period, no deconditioning occurred. A change to their pre-tracheostomy ventilator settings was not always necessary and weaning could begin promptly. By avoiding the typical 7-10 day period of intubation and deconditioning, it is approximated ITU stay could be cut by up to 7 days. This can have a significant economic impact in both ITU bed days as well as physical capacity. We devised a safety checklist to maintain safety during the procedure, advocating the use of ultrasound whilst remaining aware at all times of the potential urgent need for airway protection.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122665071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Peripheral nerve injury is a rare but significant perioperative complication. Despite a variety of investigations that include observational, experimental, human cadaveric and animal studies, we have an incomplete understanding of the etiology of PPNI and the means to prevent it. In this article we reviewed current knowledge pertinent to perioperative upper extremity peripheral nerve injury and optimal intraoperative patient positioning.
{"title":"Perioperative Upper Extremity Peripheral Nerve Injury and Patient Positioning: What Anesthesiologists Need to Know","authors":"I. Kamel","doi":"10.23880/accmj-16000155","DOIUrl":"https://doi.org/10.23880/accmj-16000155","url":null,"abstract":"Peripheral nerve injury is a rare but significant perioperative complication. Despite a variety of investigations that include observational, experimental, human cadaveric and animal studies, we have an incomplete understanding of the etiology of PPNI and the means to prevent it. In this article we reviewed current knowledge pertinent to perioperative upper extremity peripheral nerve injury and optimal intraoperative patient positioning.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128686942","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
EHR (Electronic Health Records) documentation is one of the critical components of today’s medical field. It helps capture and organize the patient’s data electronically. Yet the knowledge related to EHR is not fully clear and their impact is adversely seen due to dampening doctor-patient relationship with increase screen time. There always been a hope that the EHR system would increase the time providers spend with patients. The aim of this article is to provide insights to save time in front of computers for doctors. Saving time includes better training to the providers, strong software and hardware infrastructure, revisiting good practices to improve efficiency and finally, effective EHR data capturing.
{"title":"Opinion Piece: Providers - Computers - Patients (Technology Wall in Healthcare)","authors":"Venkatraman Palabindela","doi":"10.23880/accmj-16000153","DOIUrl":"https://doi.org/10.23880/accmj-16000153","url":null,"abstract":"EHR (Electronic Health Records) documentation is one of the critical components of today’s medical field. It helps capture and organize the patient’s data electronically. Yet the knowledge related to EHR is not fully clear and their impact is adversely seen due to dampening doctor-patient relationship with increase screen time. There always been a hope that the EHR system would increase the time providers spend with patients. The aim of this article is to provide insights to save time in front of computers for doctors. Saving time includes better training to the providers, strong software and hardware infrastructure, revisiting good practices to improve efficiency and finally, effective EHR data capturing.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129146378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Perioperative hypothermia has been strongly associated with poor outcomes in children undergoing general anesthesia. Methods: This study consisted of a monocentric, block randomized, double blinded, placebo-controlled clinical trial over a period of 3 months at a tertiary referral center. Non-febrile patients with no significant medical history younger than 3 years and having surgery for a minimum duration of one hour under General Anesthesia were chosen. Thirty minutes prior to emergence, patients received either IV Acetaminophen (Group P) or a placebo solution of normal saline (Group N). The temperature was recorded at T0, T15, T30, T45 and T60 intervals. Results: 60 out of 84 patients were enrolled, the sample consisted of 58.3% (n=35) males and 41.7% (n=25) females with a mean age 1.16 ± 0.92 years. When using a t test to compare the mean core temperature, at a 95% Confidence Interval and ±=0.05, data showed that in Group P (35.52 ±0.68 oC < 36°C) and in Group N (36.07 ±0.71 oC > 36°C) were significantly different at T30 (p<0.005). A similar significance was observed at T45 yet not at T60. Conclusion: Acetaminophen seems to have induced a significant transient hypothermia at T30 in the pediatric population, which coincides in this study with the critical time of emergence. At T60, no significant difference was observed, suggesting that patients’ core body temperature values returned to normality. Therefore, it is recommended to administer Acetaminophen at least 60 minutes prior to emergence to avoid a core temperature drop during this critical phase.
{"title":"Acetaminophen Induced Transient Hypothermia in Pediatrics Population Undergoing General Anesthesia; a Double Blinded Randomized Controlled Clinical Trial","authors":"Kafrouni Hf","doi":"10.23880/accmj-16000194","DOIUrl":"https://doi.org/10.23880/accmj-16000194","url":null,"abstract":"Background: Perioperative hypothermia has been strongly associated with poor outcomes in children undergoing general anesthesia. Methods: This study consisted of a monocentric, block randomized, double blinded, placebo-controlled clinical trial over a period of 3 months at a tertiary referral center. Non-febrile patients with no significant medical history younger than 3 years and having surgery for a minimum duration of one hour under General Anesthesia were chosen. Thirty minutes prior to emergence, patients received either IV Acetaminophen (Group P) or a placebo solution of normal saline (Group N). The temperature was recorded at T0, T15, T30, T45 and T60 intervals. Results: 60 out of 84 patients were enrolled, the sample consisted of 58.3% (n=35) males and 41.7% (n=25) females with a mean age 1.16 ± 0.92 years. When using a t test to compare the mean core temperature, at a 95% Confidence Interval and ±=0.05, data showed that in Group P (35.52 ±0.68 oC < 36°C) and in Group N (36.07 ±0.71 oC > 36°C) were significantly different at T30 (p<0.005). A similar significance was observed at T45 yet not at T60. Conclusion: Acetaminophen seems to have induced a significant transient hypothermia at T30 in the pediatric population, which coincides in this study with the critical time of emergence. At T60, no significant difference was observed, suggesting that patients’ core body temperature values returned to normality. Therefore, it is recommended to administer Acetaminophen at least 60 minutes prior to emergence to avoid a core temperature drop during this critical phase.","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"76 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134177720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Intraoperative Fraction of Inspired Oxygen: An Enigma to be Unravelled","authors":"J. Agrawal","doi":"10.23880/accmj-16000163","DOIUrl":"https://doi.org/10.23880/accmj-16000163","url":null,"abstract":"","PeriodicalId":313122,"journal":{"name":"Anaesthesia & Critical Care Medicine Journal","volume":"60 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"1900-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123483443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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