The ventilatory management of trauma patients can present significant challenges. Its main aims focus on the reduction of the work of breathing, facilitation of an improvement in gaseous exchange, and on the avoidance of ventilation-induced lung injury (VILI). VILI is a pathophysiologic process consisting of several changes seen in ventilated lungs that have been attributed to the ventilation strategy employed subsequent to the traumatic lung injury. In order to avoid the major components of VILI, both maximal alveolar aeration and recruitment are needed to minimize the shear stresses in the injured lung tissue. Alveolar recruitment maneuvers have become the major goals of mechanical ventilatory support for patients with severe trauma over the last few decades. The importance of early lung recruitment with an ‘open lung’ approach has been well documented in several studies and its application has been shown to preserve lung mechanics, attenuate lung mechanotrauma, and thereby reduce mortality during ventilation. Controversies nonetheless exist regarding the most appropriate form of their use in patients with pulmonary injuries as recruitment maneuvers may have several adverse effects. The main concerns center on exploiting high airway pressures during the recruitment process and its potential harmful consequences, such as barotrauma and hemodynamic compromise. The purpose of this article is to review the major concepts in the mechanical ventilation literature that outline the principles for the use of the open lung management strategy in patients that have been subjected to significant trauma and to delineate both the major techniques of lung recruitment as well as their potential complications.
Traumatic tension pneumothorax is a life-threatening injury encountered in pre-hospital trauma patients. Decompression with needle thoracostomy is a technique that can reverse this condition. No intercostal artery injuries from needle decompression (ND) have previously been reported. A 28-year-old man presented with hemorrhagic shock from multiple stab wounds and concern for tension pneumothorax treated with ND in the pre-hospital setting. Despite embolization of the patient’s initial arterial injuries he developed life-threatening hemothorax. Thoracotomy revealed intercostal artery laceration in the region of his ND. ND remains a critical life-saving procedure in tension pneumothorax, but proper technique and site selection is required to minimize complications. *Correspondence to: Ravi Chauhan, Defence Medical Services, Camberley, United Kingdom, E-mail: ravi.chauhan@me.com Received: April 20, 2018; Accepted: May 17, 2018; Published: May 24, 2018 Introduction Trauma is the leading cause of death for Americans aged between 1-46 years of age and the third leading cause of death in the United States overall [1]. It is the leading cause of mortality globally [2]. Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems. All trauma patients require a systematic approach to management in order to maximize outcomes and reduce the risk of undiscovered injuries. A clear, simple, and organized approach is needed when managing a severely injured patient. The assessment disseminated in Advanced Trauma Life SupportTM (ATLSTM) provides such an approach [3]. The primary and secondary surveys allow rapid identification of potentially reversible life-threatening injuries in the pre-hospital or in-hospital setting. Identification and treatment can mean the difference between life and death. Such injuries include airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest and cardiac tamponade. The procedures to manage these injuries, however, can be fraught with complications. We present the first case of iatrogenic intercostal artery (ICA) injury resulting in life-threatening massive hemothorax from emergent needle decompression (ND) – a lethal injury as a consequence of a life-saving intervention. We briefly review the literature surrounding vascular injuries and discuss some of the alternative options for management of tension pneumothorax and why this case may have presented in a delayed manner. Case report A 28-year-old male with no past medical history presented by ambulance after suffering multiple stab wounds. EMS reported concern for tension pneumothorax prior to arrival and performed field needle decompression of the left anterior chest wall. Due to inability to obtain vascular access, an intraosseous needle was placed by EMS in the right humeral head. At the time of presentation, he was afebrile (36.1 C), with blood pressure 72/40 mm Hg, heart rate 108 beats/min, respiratory rate 22 breath/min, and oxygen saturation 100% while on supplemental oxygen at 15 L/min via non-rebreather mask. Auscultation revealed tachycardic normal heart sounds and bilateral breath sounds. Abdominal examination was soft. The patient had four stab wounds including three superficial wounds present on the right shoulder, left upper paravertebral back, and left middle paravertebral back. A deep stab wound to the left lateral upper back was continuously bleeding despite manual pressure by EMS. Pertinent laboratory findings included hemoglobin 10.2 g/L, platelets 192 K/mcL. Potassium 2.5 mmol/L, bicarbonate 16 mmol/L, lactate 7.9 mmol/L, INR 1.4, TEG clotting time 5.2 min. The prominent left lateral upper back wound continued to bleed despite packing with sterile gauze and manual pressure at bedside. Due to inability to obtain large bore peripheral access a central venous catheter was placed in the right subclavian for administration of blood products. The patient was intubated due to waxing mental status and repeated non-bloody emesis. Bedside chest radiograph after intubation showed right-sided pneumothorax (suspected iatrogenic from attempted subclavian line placement) (Figure 1). Computed tomography angiography (CTA) confirmed active hemorrhage from branches of the patient’s left axillary artery (Figure 2A/2B). The patient was taken emergently to the operating room for angiography. Angiography confirmed active hemorrhage from branches of the subscapular artery (Figure 3). Selective catheterization and coil embolization of the circumflex scapular artery successfully stopped all further extravasation from that site. The patient then underwent closure of his stab wounds. Post-operatively he developed hemodynamic instability in the Intensive Care Unit and was found to have massive left hemothorax (Figure 4). Tube thoracostomy immediately Gatz JD (2018) Emergent needle decompression for tension pneumothorax resulting in life threatening intercostal artery injury Volume 3(1): 237-240 Glob Anesth Perioper Med, 2018 doi: 10.15761/GAPM.1000163 of stab injury in this area other than the patient’s known pre-hospital needle decompression. Hemorrhage was successfully controlled after ligation of the medial and lateral components of the bleeding ICA. The patient’s hemodynamics stabilized following the procedure and he was discharged one week later.
A low score on the Glasgow Coma Scale (GCS) [1], is a common presentation in acute hospital settings.Anesthesiologists and intensivists are frequently asked to ensure airway protection in such patients.Endotracheal intubation is necessary if the GCS is very low.However, it is important to confirm that consciousness is really impaired and the airway is unprotected because endotracheal intubation is demanding and not without risks.In a recent experience with two cases of low GCS, the plan for endotracheal intubation was unnecessary, as the patients were actually capable of protecting their airway.
Trauma to the neck can present significant challenges to securing an airway.Isolated fractures of the larynx are uncommon injuries.They are frequently associated with difficult mask ventilation and intubation that can result in significant morbidity.We present a case of a 56 years old male with increasing respiratory distress following a horse bite to the neck.An awake fiberoptic intubation was attempted but was unsuccessful.Hence, a decision to quickly proceed with a cricothyroidotomy was made.It is important to immediately recognize the need for a surgical airway to decrease the risk of airway related complications.
Perivalvular leak is a serious, yet uncommon complication of prosthetic mitral valve replacement.1-3% of these patients require re-operation due to development of symptoms of heart failure and/or hemolysis.We present a patient who returned to the hospital in fulminant heart failure 4 months after an MVR due to a perivalvular leak not caused by endocarditis.We discuss the typical pathology and implications of a prosthetic valve dehiscence and the challenges these patients present in the perioperative period along with the clinical significance of perivalvular leak not due to endocarditis.
The use of transesophageal echocardiography in obstetric anesthesia is uncommon and rarely reported during cesarean section.To our knowledge, this is the first report of its use for intraoperative surveillance of a tumor thrombus that has invaded over 90% of the inferior vena cava and was at risk of embolizing in a patient undergoing a cesarean section.We decided to use transesophageal echocardiography in this case to directly observe the IVC tumor which would allow for early intervention and to potentially avoid impending cardiovascular collapse.This case also reports a rare tumor that was incidentally found in late pregnancy which made a safe delivery to be very challenging.
BACKGROUND:The management and outcome of elderly patients aged 65 years and above admitted to the intensive care unit (ICU) are often complicated by the presence of co-morbidities and reduced physiological reserve.METHODOLOGY:This was a retrospective, case-control study. Patients aged 65 years and above admitted to the unit from January 2012 to June 2013 were included in the study. Admission and discharge register in the ICU was examined. A patient before and after each elderly patient were recruited to serve as controls in the study.RESULTS:Seventy-nine (79) elderly patients were admitted to the ICU and it constituted 12.6% of total ICU admission with a mortality rate of 49.6%. Male:Female ratio was 2:1. Postoperative care constituted the highest indication for ICU admission (41.8%) followed by cerebrovascular accident (stroke), 12.6%. Younger patients were about twice more likely to be mechanically ventilated than elderly patients. (p=0.05, OR=1.855) Conclusion: The mortality rate of elderly patients admitted to the ICU was high. Appropriate admission criteria and protocol for the management of elderly patients in the ICU should, therefore, be developed to improve outcome.
Objective: The World Health Organisation Surgical Safety Checklist improves surgical outcomes in resource poor settings but the best method of implementing the checklist is unknown. We aimed to evaluate three different methods of training in Guinea and evaluated the outcome at 3–6 months. Methods: A total of 13 individuals (4 surgeons, 7 anaesthetists and 2 nurses) from 6 different hospitals underwent 3 methods of training (hospital team training, hospital individual training and classroom only training). None had previous knowledge the checklist. Effectiveness of training was evaluated by hospital visits and structured interview at 3-6 months. Corroborating evidence was obtained from interviews with the Hospital Directors and other staff. Findings: Team training was the most successful. All the hospitals who received team training reported improvements in teamwork, anaesthesia, and infection control. No hospital managed to implement the checklist in its entirety. Anaesthetists who received individual training were unable to implement any changes in their own hospitals. Conclusion: Team training is more effective than individual training in ensuring more of the key steps of the checklist are followed. Our results question the effectiveness of running a one day classroom training for implementation of the WHO checklist for single groups of professionals such as anaesthetists in the absence of support from other members of the operating team. Correspondence to: Dr. Michelle C. White, Consultant Anaesthetist, Mercy Ships, Toamasina, Madagascar, USA; Tel: + 1 954 538 6110; E-mail: doctormcw@gmail.com
Background: To compare the effects of epidural and spinal analgesic regimens on outcomes for patients undergoing laparoscopic ventral rectopexy (LVR) within a fast-track care pathway. Material and methods: This study is a retrospective analysis of prospectively collected data from two time periods. From 2007 to 2009, a total of 38 consecutive patients underwent a standardized LVR within fast-track care pathway and epidural analgesia. The spinal analgesia group consisted of 42 consecutive patients who received similar LVR from 2013 to 2014. Totally intravenous anesthesia regimen and fast-track care pathway were similar during both study periods. The main measures of outcome were postoperative hospital stay, pain scores, and postoperative opioid consumption with 30-day morbidity and readmission rates as secondary outcomes. Results: The study groups were well balanced for baseline characteristics. Postoperative hospital stay was shorter in the spinal than in the epidural group (median 2 versus 3 days, p<0.02). Fifteen of the 42 patients (35.7%) in the spinal group were discharged on postoperative day one versus none in the epidural group. Pain scores were higher in the epidural group on postoperative day one. There were no deaths and only one complication and one conversion to open surgery in the spinal group. Conclusion: Spinal analgesia is a safe analgesic regimen for patients undergoing LVR, and improves mobilization and shortens postoperative stay compared with epidural analgesia in the fast-track setting. Correspondence to: Ilmo Kellokumpu, Department of Surgery, Central Hospital of Central Finland Keskussairaalantie 19, 40620 Jyväskylä, Finland, Fax: +35814-2692929; E-mail: ilmo.kellokumpu@ksshp.fi
Background: Ultrasound-guided transversus abdominis plane block is an effective method for pain relief after cesarean delivery. The gold standard to treat pain after cesarean delivery is spinal morphine administration; at the same time TAP is considered as an effective method to treat this pain. In this study, we compared efficiency and side effects of these techniques in patients undergoing elective cesarean delivery. Methods: 104 women undergoing elective cesarean delivery under spinal anesthesia were randomized to receive either TAP block with Bupivacaïne 0.25% (BUPICAÏNE, UNIMED, TUNISIA) or spinal morphine. All patients received a standard postoperative analgesia with Paracetamol intravenously. Rescue analgesia using Nefopam and morphine intravenously was given when necessary. Patients were assessed at 2, 4, 6, 12 and 24 hours after cesarean delivery. Visual analog scale (VAS) pain scores at rest and during the palpation of the uterine globe were recorded. Analgesic consumption, time to first analgesic request, heart rate, systolic and diastolic blood pressure were noted. Patients rated the severity of opoid side effects and their satisfaction with the protocol of analgesia. Results: Pain scores at rest and during the palpation of the uterine globe during the first 24 postoperative hours were similar in both groups. The number of patients who received additional analgesia was similar in both groups. The intestinal transit recovery was earlier in the TAP block group with a statistically significant difference (p < 10-3). Maternal satisfaction was similar in both groups. Conclusion: TAP block and intrathecal morphine were of similar efficiency for pain relief after cesarean section. The incidence of side effects was comparable in both groups. Correspondence to: Sofiene Ben Marzouk, Anesthesiologist, University Hospital Assistant, Center Of Maternity And Neonatology , La Rabta, Tunis, Tunisia, Tel: 0021699941968; E-mail: bmarzouksofiene@live.fr
It is economically useful and ethical to improve surgical aseptic practice. A survey among OR-personnel revealed Situation-sensitivity, Reference-sensitivity, Ethicalsensitivity, and Infection-sensitivity factors for self-reported reasoning for adherence to aseptic practice recommendations. There were differences in reasoning between nurses and physicians in the pilot study. The follow-up study among nurses only revealed lack of interest and need to study more the recommendationadherence of nurses. Identifying the reasoning for recommendationadherence it may be possible to improve outcomes of infection prevention programs. Correspondence to: Aholaakko Teija-Kaisa, Laurea University of Applied Sciences, Vantaa, Finland; +358 46 8567 348, Fax +358 9 8868 7301: E-mail: teija-kaisa.aholaakko@laurea.fi Received: August 18, 2016; Accepted: September 24, 2016; Published: September 28, 2016 Introduction According to World Health Organization (WHO) [1] health care associted infections (HCAI) are the most frequent adrverse event of patients while obtaining care. The impact of HCAI implies prolonged hospital stay, long term disability, and excess deaths for the patients, and increased costs for the families. For the health-care system HCAIs imply increased resistance to antimicrobials, and massive additional financial costs. In Europe annual financial losses are estimated at approxymately € 7 billion every year including direct costs only. In USA, approxymately 99 000 deaths in 2002 and annual economic impact at approxymately US$ 6.5 billion in 2004, were attributed to HCAIs. In lowand middle income countries surgical site infection (SSI) is the most frequent type of HAI. The rates are varying from 1.2 to 23.6 infections per 100 surgical procedures. In developed countries SSI follows after urinary tract infections and the SSI-rates vary between 1.3 and 5.2%. In 2011 in United States [2] 4% of acute care inpatients had at least one HCAI. The most common HCAIs were SSI (24.3%) and pneumonia (24.3%) with estimated numbers of 157 500 each. The Association for Profesionals in Infection Control (APIC) [3] has published a program to eliminate HCAIs. APIC aims zero tolerance. One of their goals is to influence and facilitate legistative, accreditation, and regulatory agenda for infection prevention (IP) with consumers, policy-makers, health care leaders, and perssonnel. Also WHO considers the promotion of protective measures and best practices key priorities in reducinge the burden of HCAI. Appropriate hand hygiene and correct application of precautions during invasive procedures are key components in IP. In the performance of these simple and low-cost IP-interventions staff accountability is essential. When the staff doesn’t apply precautions the behavioral [1] and culture change [4] is required. In improving perioperative aseptic practice (AP) understanding of human behavior is beneficial.
A 55-year-old man was scheduled to get a L4-5 decompression surgery due to spinal stenosis.He received occipitocervical fusion because of traffic accident in 1999 and he had cleft palate of 3*5 cm and his nasal opening also showed abnormality.As there was a concern about the difficult airway, awake intubation using fiberoptic bronchoscope was considered.After the patient was sedated, oral fiberoptic intubation was attempted.But, unexpectedly when the bronchoscope fell into the nasal cavity through cleft palate, it became difficult to get a view and thus it was also difficult to find a normal structure.After about 5 minutes of attempt, his sedation deepened and his oxygen saturation gradually decreased to less than 90%.After oxygen saturation was secured 100% with assisted ventilation, intubation was attempted by using Glidescope.It was difficult to get a proper view and insert endotracheal tube, but intubation was successful when the second attempt was conducted.After then, 100 mg of propofol and 50 mg of esmeron were administered and general anesthesia was performed by using desflurane.After about 1 hour, surgery ended and the patient's spontaneous respiration was recovered sufficiently.After observing him obeying our command, his tube was removed.He was transferred to a recovery room and when all of his vital signs were observed to be stable, he was instructed to leave the room.
Background: Malignant hyperthermia can be induced by halogenated anesthetics that are inadvertently retained in the anesthetic circuit. Therefore, we compared the desflurane washout times of three different anesthesia workstations. Methods: The AisysTM, Fabius GSTM, and Pro-nextTM workstations were selected and each workstation was tested after connecting a 1-L test lung to the patient side and volume-controlled ventilation was performed with 500 mL tidal volume, a respiratory rate of 10/min, and O2 flow of 1.5 L/min. When the end-tidal concentration of desflurane reached 6%, the flow of desflurane was stopped and the time until desflurane had completely disappeared from the circuit under continuous gas flow was measured. Results: The mean washout times were 175 ± 5.5 s for the AisysTM system, 216 ± 13s for the Fabius GSTM system, and 254 ± 31 s for the Pro-nextTM system. The calculated washout times per circuit capacity were 175 ± 5.5 s/L for the AisysTM system, 216 ± 13 s/L for the Fabius GSTM system and 254 ± 31 s/L for the Pro-nextTM system. The AisysTM system provided significantly shorter times compared with the other systems. Conclusion: The AisysTM system provided the shortest washout time for desflurane. These findings may help prevent malignant hyperthermia among patients who are preparing to undergo anesthesia. Correspondence to: Shinsuke Hamaguchi, MD, PhD, Professor and Chairman, Department of Anesthesia and Pain Medicine, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan; Tel: +81282-86-1111 (ext. 2771); Fax: +81-282-86-0478; E-mail: s-hama@dokkyomed.ac.jp
Operation of intramaxillary fixation that is required treatment of jaw fracture require long operation time, where intravenous sedation is adaptable to operation of intramaxillary fixation. Four cases were performed anesthesia and systemic management by author anesthesiologists. Anesthesia record was studied about adverse event (body movement, hemodynamic changes and pain complaint) in each case. Four patients classed in ASA physical status I. In intravenous sedation case using sedative or pentazocine combining sedative, hemodynamic changes and body movement were observed during operation. In intravenous sedation or systemic management cases of using fentanyl, body movement and hemodynamics changes were not observed during operation. Glossoptosis and hypopnea were not observed in four cases. The sedation is inhibited, if pain control is insufficient. The pain control using local anesthetic is difficult for pain of intramaxillary fixation operation. Fentanyl, specialized analgesic by high selectivity with μ receptor, is useful for operation of intramaxillary fixation, because local anesthetic is not provided enough analgesia. In conclusion, in intravenous sedation for intramaxillary fixation operation, the full agonist opioid such as the fentanyl, specialized in analgesia, is useful to provide enough analgesia. Correspondence to: Dr. Kentaro Ouchi, Department of Dental Anesthesiology, Field of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University Graduate School, Japan, Tel: +81-92-641-1151; Fax: +81-92-642-6481; E-mail: ken2006anes@yahoo.co.jp
Polycythemia vera (PV) is a stem cell disorder characterized as a panhyperplastic and a neoplastic marrow disorder.PV is relatively rare, and extremely uncommon in pediatric patients.The following describes perioperative and anesthetic management of a pediatric patient with polycythemia vera presenting for surgery.
