BACKGROUND:We conducted this prospective controlled observational study to compare the effect of ethnicity on the risk of postoperative nausea and vomiting (PONV) between moderate to high-risk African and non-African patients undergoing general anesthesia.METHODS:Using Apfel score risk factors and predicted length of surgery (>30 minutes), 89 moderate to high risk patients undergoing general anesthesia were recruited in a university hospital between March 2009 and November 2010. Thirty patients in the non-African group and 59 patients in the African group were allocated using an ethnicity self identification questionnaire. Intraoperative anesthesia was standardized. PONV was assessed at 0 minutes, 15 minutes, 90 minutes, 180 minutes, and 24 hours. Generalized linear mixed effects models was used to determine the effect of ethnicity on PONV.RESULTS:Despite similar Apfel scores, cumulative incidence of postoperative nausea was higher in the non-African group at 0 minutes (46.67% vs 22.03%, P = 0.019), 15 minutes (70% vs 23.73%, p<0.001) and 90 minutes (36.67% vs 16.95%, P = 0.04). The non-African group had more episodes of vomiting over 24 hours (13.33% vs 1.69%, P = 0.055). Non-Africans had a 25 times higher reported nausea incidence than Africans over 24 hours.CONCLUSION:The incidence of PONV in non-Africans is significantly higher than in Africans. Non-African ethnicity is an independent risk factor for PONV. Current risk prediction models may be limited in multi-ethnic populations and further investigations are warranted to examine ethnicity as a risk factor.
When maternal cardiac arrest occurs before 24 weeks of gestation, the purpose of cardiopulmonary resuscitation (CPR) is to resuscitate the mother. If she is resuscitated, it is likely that pregnancy will proceed. Emergency delivery of the fetus is not likely to improve the maternal chances of survival. In contrast, at or beyond 24 weeks of gestation, delivery of the fetus may actually improve maternal survival by decreasing aorto-caval compression with a consequent improvement of venous return and cardiac output. In addition, chest compression will be more effective once the gravid uterus is evacuated, and the functional residual capacity of the lung will increase with a consequent increase of maternal oxygenation and resuscitation efforts1,2.
Charcot-Marie-Tooth disease comprises a group of disorders characterized by progressive muscle weakness and wasting. Reviewing the anaesthetic literature produced conflicting reports about the best anaesthetic options for patients with CMTD; as they are at increased risk of prolonged response to muscle relaxants, malignant hyperthermia and risks of regional anaesthesia. We present a case of the successful use of total intravenous anaesthesia with dexmedetomidine and propofol combined with caudal block using bupivacaine mixed with dexmedetomidine without any complications, for a 17 year old male patient with Charcot Marie-Tooth disease who underwent a lower limb orthopedic surgery.
ContextCircumcision is one of the most common surgical procedures in pediatric males.Anesthesia is often the classic dorsal penile nerve block (DPNB), which is based on landmarkidentification and tactile feel of tissue resistance during needle advancement. However, thistechnique is associated with technical failures and vascular complications.ObjectiveWe used an ultrasound-guided in-plane technique to avoid injury of penilevascular and neural tissues during DPNB. The aims of this retrospective study were to compare thesuccess rate and efficacy of these two penile block techniques.MethodsMale pediatric patients undergoing circumcision received general anesthesiabefore the penis and surrounding area were prepared with 0.5% chlorhexidine in 70% alcohol.Sixteen patients underwent classic DPNB, and 16 underwent the modified ultrasound-guided inplanetechnique. The ultrasound machine was adjusted to the musculoskeletal setting, and a linearultrasound probe with a frequency range of 5 to 10 MHz was placed transversely along the base of the penis, which received gentle traction.ResultsThough not statistically significant, patients who underwent the classic DPNB wereapproximately 1.8 times more likely to require rescue analgesia and approximately 2 times morelikely to have a complication than those in the ultrasound-guided group. Results also showed lowervolume requirements for local anesthetic and intraoperative narcotics, longer time until rescueanalgesic, and lower incidence of vomiting in the ultrasound-guided group than in the landmark-guided group.ConclusionsThe ultrasound-guided DPNB technique appears to offer advantages overclassic DPNB and warrants a prospective controlled trial to confirm these findings.
Ludwig’s angina, although uncommon, remains a potentially life-threatening condition because of the risk of impending airway obstruction. Effective treatment is based on early recognition of the clinical process, with the appropriate use of parenteral antibiotics, securing the airway, and formal surgical drainage of the infection. Awake fiberoptic intubation under topical anesthesia may be the preferred method to secure the airway. Flexible nasotracheal intubation requires skill and experience. When fiberoptic bronchoscopy is not feasible, not available, or has failed, an elective awake cricothyrotomy and tracheostomy are the options. Furthermore, the introduction of newer advanced airway techniques, such as video-assissted laryngoscopy, may allow the clinician additional flexibility in nonsurgical airway management. We present a recent case of a patient with Ludwig’s angina, successfully managed at our hospital, with a brief review of airway management options.
BACKGROUND:This prospective, randomized, single blind, single operator study was conducted to compare hemodynamic responses when endotracheal intubation was performed using the Bonfils intubation fibrescope versus the C-MAC videolaryngoscope.METHOD:Forty-four ASA I patients aged between 18 and 60 years, scheduled for elective surgery requiring endotracheal intubation were recruited. They were randomized into the Bonfils group or C-MAC group. Hemodynamic changes, laryngeal view, duration of intubation and post intubation complications were evaluated. Mean arterial pressure, heart rate and oxygen saturation were monitored pre and post-induction, pre and post-intubation, and at 1 minute intervals thereafter for 10 minutes.RESULTS:Endotracheal intubation was successful at first attempt in 90.9% in both groups. Heart rate was significantly higher in the Bonfils group (p < 0.05) compared to the C-MAC group and values were sustained throughout the study. There was no difference in the mean arterial pressure (MAP) between the two groups. Mean time to intubation was significantly longer in the Bonfils group (28.8 vs. 24.7 seconds, p = 0.02). There were no significant differences in laryngeal view and post intubation complications between the groups.CONCLUSION:Intubation using the Bonfils intubation fibrescope took longer, and resulted in significantly higher heart rate when compared with the C-MAC videolaryngoscope.
BACKGROUND:Gaining proficiency with various airway management tools is an important goal for anesthesiology training. Indirect video laryngoscopes facilitate tracheal intubation in adults, but it is not clear whether these findings translate to children. This study evaluates the total time to successful intubation when performed by anesthesiology trainees using GlideScope Cobalt® video laryngoscopy (GlideScope), Storz DCI® video laryngoscopy (Storz), or direct laryngoscopy (Direct) in children <2 years old with normal airway anatomy. METHODS:Sixty-five children presenting for elective surgery were randomly assigned to undergo tracheal intubation using GlideScope, Storz, or Direct. Laryngoscopists were anesthesiology trainees in clinical anesthesia year ≥2 who had proven basic proficiency with each laryngoscope on an infant airway manikin. Total time to successful intubation (TTSI, seconds), rate of successful intubation on first laryngoscopy attempt, and the change in intubation time from manikin to clinical settings were recorded. An intubation time difference >10 seconds was defined as clinically significant. RESULTS:TTSI was longer for Storz (42.1; 34.0 to 59.0) than for Direct (21.5; 17.0 to 34.3; p=0.002). We were not able to demonstrate a difference >10 seconds between the GlideScope and the other laryngoscopes. Median manikin intubation time was <10 seconds and increased significantly in the clinical setting for all laryngoscopes (all p <0.0001). CONCLUSIONS:Anesthesiology trainees completed manikin tracheal intubation rapidly with all laryngoscopes studied, but required a clinically significant longer time to tracheally intubate children <2 years. Our findings suggest in vivo training should be included to facilitate proficiency with device-specific intubation techniques.
In 1986, Vern L. Katz, Deborah J. Dotters, and William Droegemueller published “Perimortem Cesarean Delivery,” an article in which they developed the Four Minute Rule for perimortem cesarean sections. The Four Minute Rule states that if a pregnant woman’s heart stops beating, physicians should begin an operation to deliver the fetus [2] within four minutes and aim to have the fetus [2] delivered within five minutes of cardiac arrest. Although cardiac arrest during pregnancy [3] is uncommon, it can happen when pregnant women experience trauma, blood clots, infection, or have preexisting heart conditions. In the article, the authors emphasize how the Four Minute Rule increased maternal and fetal survival rates and decreased cases of severe fetal brain damage. The article “Perimortem Cesarean Delivery” was the first article to present the Four Minute Rule, which has influenced international guidelines and become the standard for maternal resuscitation and fetal survival in emergency medicine, operating rooms, and many other aspects of medical practice.
OBJECTIVES:To compare the analgesic efficacy of intrathecal Ketamine and fentanyl added to bupivacaine in patients undergoing cesarean section.METHODS:Ninety patients 18-40 years old were recruited in a prospective double-blinded, randomized way. Spinal anesthesia was performed in the three groups by using bupivacaine 10mg combined with 0.1mg/kg ketamine in group K, bupivacaine 10mg combined with 25 µg fentanyl in group F and bupivacaine 10mg combined 0.5 ml distilled water in group P. The time to first analgesic request, analgesic requirement in the first 24 hours after surgery, sensory and motor blockade onset time, duration of sensory and motor blockade, the incidence of adverse effects were recorded.RESULTS:The mean time to first analgesic request was longer in group K (296.80 ± 32.46) compared to group F (277.87 ± 94.25) and group P (235.43 ± 22.35). The difference between group K and F (P = 0.504) was not significant but the difference between group K and group P (P <0.001) and group F and group P (P = 0.042) was significant.CONCLUSION:Addition of ketamine or fentanyl to spinal bupivacaine were equally effective in pain control after cesarean section and therefore, based on the specific conditions of patients, ketamine at concentrations mentioned earlier, could be a proper alternative to achieve postoperative analgesia
Background:Background: The nature of massive mass gathering during Hajj was expected to provide a challenging and stimulating working experience for anesthesiology training program residents. An new rotation arrangement was reached between the Ministry of Health and the Saudi Commission of Health Specialties to recruit anesthesia resident to provide critical care services during the Hajj seasons in 1434 and 1435. Objectives:This study aimed to explore the perspectives of anesthesia residents on their experience working among critical care teams during Hajj seasons in 1434H and 1435H at various locations of Makkah city and Al-Mashaer. Subjects and methods:This cross-sectional study was conducted using a self-administered questionnaire distributed to all residents (n = 35) enrolled in anesthesia residency training program of the SCFHS and participated in critical care areas as locum during the Hajj seasons of 1434H and 1435H. Data was analyzed by using the statistical package of social science. Results:The mean score of residents agreement on being treated with respect from both nurses and administration was the highest among the surveyed item (6.13 and 6.22 respectively). It was observed that, satisfaction of the residents with the direct observations and feedback provided to them (p = 0.01), the adequacy of the services components (p = 0.01) being treated with respect by the senior doctors and nurses (p = 0.03, p = 0.002) was significantly increased in the year 1435 compared to that of the year 1434. The satisfaction was generally higher in Makkah hospitals when compared to that of Al-Mashaer (Arafat and Menna) hospitals although this difference was of no statistical significance. Conclusion:Hajj critical care rotations in 1434 and 1435 were well perceived by anesthesia residents. They found them useful as they give them the chance to gain self-confidence and experience the provision of healthcare services for mass gathering sessions.
Study Objective: To study the effects of circuit leak development over time and response during volume and pressure controlled ventilation using low flow in human patient simulator and to examine the minimum fresh gas flow needed to compensate for such a leak.Design/Setting: Prospective study using a patient Simulation Lab at Wayne State University.Measurements: A human patient simulator was endotracheally intubated. The endotrachealtube (ETT) was connected to the Datex-Ohmeda AS/3 Anesthesia machine. The tidal volume wasset to 500ml in the volume controlled trial and the pressure to 6cm H2O in the pressure controlledtrial. A hole was created in each experiment placed 10 cm after the inspiratory valve. Leaks weresimulated from holes using 4 different needle diameters: 25, 21, 18 and 16G. A series of data werecollected using fresh gas flow at 4 different flow rates (0.5, 1, 1.5 and 2 liters.min-1). Data wasmeasured at different time points (baseline, 1, 3 and 5 minutes) in the series of simulated leakingbreathing circuits.Results: Leak alarms were only detected with 16G hole at 5 minutes in the volume controlmode versus leaks at 3 minutes with 16G hole and at 5 minutes with 18G hole in the pressurecontrol mode.Conclusion: When a very low flow of 0.5 L/min is used, volume control is safer than pressure control modes.
cervical radiculopathy (cr) is a relatively common disorder manifested with neck pain, radicular arm pain, at times associated with neurological signs (paraesthesia, reduced muscle strength, reduced/absent reflexes). Commonly, it results from nerve root dysfunction, secondary to mechanical compression; although cytokines released from damaged intervertebral disks are also responsible. A diagnosis is established from a thorough history, physical examination corroborated by the findings from magnetic resonance imaging (MRI). CR is typically self-limiting with up to 90% of patients achieve symptomatic improvement with conservative management (immobilization, anti-inflammatory medications, physical therapy, cervical traction, and epidural steroid injections)1. Cervical epidural steroid injections (CESI) is an effective non-surgical treatment option to manage severe radicular pain2. However evidence supporting the effectiveness of cEsi is relatively weak because of a lack of prospective randomized studies3. We performed this prospective study to evaluate the effectiveness of cEsi in patients with cr secondary to a single level herniated intervertebral disc.
Neostigmine is the classic acetylcholinesterase antagonist, which is widely used for reversal of neuromuscular block of all nondepolarising relaxants. This is a pharmacodynamic effect secondary to inhibition of the acetylcholine esterase at the neuromuscular endplate, resulting in a subsequent increased and prolonged effect of acetylcholine on the free endplate receptors. That is why, an overdose of nondepolarising muscle relaxant, blocking the entire endplate receptors' pool cannot be antagonized by neostigmine resulting in the so-called " neostigmine-resistant curarization ". " Neostigmine-resistant curarization " has been described by Hunter 1956 1. However, Churchill-Davidson (1959) stressed the fact that there are many causes of prolonged cessation of respiration, and before the term " neostigmine-resistant-curarization " can be accepted, it is first necessary to prove that a neuromuscular block is in fact present, and secondly that neostigmine fails to reverse the block 2. Using the isolated phrenic nerve diaphragm preparation, immersed in Krebs solution. Baraka (1964) demonstrated that there is a ceiling to the maximum reversal capacity of neostigmine. Neostigmine could not reverse neuromuscular block of an overdose of tubocurarine which was added to the perfusion bath 3,4. This in-vitro-observation was confirmed in vivo by Baraka (1967) who showed in man that reversal of neuromuscular block by neostigmine depended on the degree of neuromuscular block and the plasma level of tubocurarine at the time of reversal. Neostigmine could not reverse the doses of tubocurarine that are much greater than the blocking dose. In addition, the report showed that the plasma level of tubocurarine following reversal by neostigmine is not significantly different from that observed without neostigmine reversal, suggesting the fact that reversal of nondepolarising block by neostigmine is a pharmacodynamic, and not a pharmacokinetic effect 3. This finding has been confirmed by Waser who showed that the radioactive curare concentration in the diaphragm remains the same before and after reversal of neuromuscular block by neostigmine 5. That is why, reversal of curare by neostigmine cannot be achieved if the whole endplate receptor pool is occupied by the neuromuscular blocker. The degree of reversal of nondepolarising neuromuscular block by neostigmine can be monitored by the train-of-four fade (Hassan Ali et al, 1975) 6. TO -F fade ratio <0.7-0.9 is associated with upper airway obstruction, inadequate recovery of pulmonary function, reduced pharyngeal muscle coordination, increased risk of aspiration, and impaired hypoxic ventilation response 7. Because of the possible limitations, and muscarinic side-effects of the pharmacodynamic reversal …
S DEADLINE JULY 1, 2016 STEWART L. COHEN, ESQ. A Lawyers Review of Critical Sedation Related Medical Malpractice Cases STEVEN SHAFER, MD PROFESSOR OF ANESTHESIOLOGY Michael Jackson, Murder, Mayhem and Mystery: The Propofol Quandary KEYNOTE SPEAKERS J.R. MARTINEZ BEST-SELLING AUTHOR Survival, Strength and Spirit www.PediatricSedationConference.com
Simulation-based medical education (SBME) and simulation-based mastery learning (SBML) has become well-established in undergraduate and graduate medical, nursing and allied healthcare training programs. Although still in its relative infancy, the use of hi-fidelity simulation to train students in a variety of health-related professions is becoming a foundational cornerstone in program curriculum in the United States and, increasingly, in the international circle. The entire investment return resulting from the inclusion of simulation training labs in healthcare programs has just begun to be realized. The future is bright for this approach to education and healthcare to become an essential tool in the resource education box for colleges, universities, hospitals and research facilities as they serve the mission of training healthcare professionals to meet the growing needs of aging populations.
CONTEXT:Epidural anesthesia provides the advantage of segmental blockade and many adjuvants have been added to shorten the onset of action, improve the quality of analgesia and prolong the duration of analgesia. Magnesium sulphate(MgSO4) by virtue of its anti-iociceptive property has been administered by various routes.AIM:To assess the effect of MgSO4 on the duration of onset of action of injection bupivacaine for epidural anesthesia in infraumbilical surgeries.MATERIALS AND METHODS:A prospective, double-blind, randomized control study was conducted in 40 patients. Group M received 15 ml of bupivacaine 0.5% + 1 ml of 50 mg MgSO4 and Group C received 15 ml of bupivacaine 0.5% + 1 ml of normal saline via epidural route. Onset time of the sensory and motor blockade were the primary outcomes studied. Highest level of sensory block, time for two segment regression, hemodynamic parameters, side effects were the secondary parameters.RESULTS:There was a significant difference between the groups in the mean onset time of sensory blockade at T8, 12.85 ± 2.32 min in Group M and 16.75 ± 1.74 min in Group C. Median level of sensory blockade was comparable. Mean onset time of motor blockade was 13.85 ± 3.28 min in Group M and 23.25 ± 3.35 min in Group C which was clinically and statistically significant. Time for two segment regression of sensory blockade was 95.75 ± 11.84 min in Group M and 55.5 ± 8.57 min in Group C which was significant. Hemodynamic parameters and side effects were comparable.CONCLUSION:Magnesium sulphate as an adjuvant provides rapid onset of epidural anesthesia and prolongs the duration of analgesia with minimal side effects.
BACKGROUND:Extubation is known to produce significant hemodynamic disturbances. There is a need to avoid increase in heart rate and blood pressure in hypertensive and cardiac patients and in vascular, neuro and intraocular surgeries.AIMS:To study the ability of dexmedetomidine to attenuate the hemodynamic responses during extubation.MATERIALS AND METHODS:80 patients of ASA Grade I-II aged 18-50 years received standard anesthesia. At the closure of skin incision, patients were randomly allocated to receive either dexmedetomidine 0.5 µg/kg (Group D) or saline placebo (Group C) intravenously over 10 minutes in a double-blind design. Heart rate (HR), systolic, diastolic and mean arterial pressures (SBP, DBP, MAP) were assessed before, during- and after extubation. Time to eye opening and extubation, sedation, complications such as coughing, laryngospasm, bronchospasm and desaturation were recorded.RESULTS:HR, SBP, DBP and MAP were comparable to basal values in group D at extubation and lower than baseline values post-extubation but significant increase was noted in group C (P <0.001). Time to extubation and eye opening were prolonged in Group D (P <0.001). Incidence of hypotension was more in group D (22%) but was transient. Incidence of coughing was lower in Group D than in group C (P <0.001). Patients in group D were more sedated for 30 minutes post extubation.CONCLUSION:Dexmedetomidine 0.5 µg/kg given before extubation attenuates hemodynamic reflexes during emergence from anesthesia without causing undue sedation, but prolongs time to extubation.
