Elective Intubation
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Letters to the Editor
letters to the Editor Porphyria, Cardiopulmonary Bypass, and heart with additional hemorrhage into the pericardial sac (5). Peri- cardiocentesis, however, can be a temporizing measure in the se- Volatile Anesthetics verely compromised patient (4,7,8) until definitive surgical estab- lishment of a pericardial window. A pericardial window can be To the Editor: established under local anesthesia (9) via the subxiphoid or lateral We take issue with Stevens et al’s contentious statements in their thoracotomy approach (1,2,5,8,9). The subxiphoid approach is less discussion of volatile anesthetics in the patient with acute intermit- useful for trauma because limited surgical exposure may preclude tent porphyria undergoing mitral valve replacement (1). repair of cardiac wounds (2). However, a pericardial window dur- In the “pre-propofol” era, the safe and appropriate use of halo- ing awake lateral thoracotomy may be both poorly tolerated and thane and isoflurane in porphyric patients was established (2). dangerous in the distressed, moving patient (7). Recent reports of the successful use of isoflurane in porphyric A blunt trauma victim (2) recently presented for an emergent patients undergoing cardiac surgery also exist (3,4). As the authors surgical pericardial window for recurrent acute pericardial tampon- themselves allude to a report of elevated porphyrins after propofol ade. Although the patient was not hypotensive, jugular venous anesthesia in acute intermittent porphyria, favoring propofol over distention, pulsus paradoxus (1,3,7), patient distress (4), and echo- inhaled anesthetics because of the latter’s implied lack of a “safety cardiographic signs were present. As an alternative to endotracheal record” cannot be supported. -
Spring 2009 Student Journal
Volume 8 Number 1 Spring 2009 The International Student Journal of Nurse Anesthesia TOPICS IN THIS ISSUE MS & ECT Cardioprotection of Volatile Agents Hyperthermic Chemotherapy Intubating LMA Pierre Robin Syndrome Alpha Thalassemia Latex Allergy & Spina Bifida Distorted Upper Airway Volunteerism – Honduras INTERNATIONAL STUDENT JOURNAL OF NURSE ANESTHESIA Vol. 8 No. 1 Spring 2009 Editor - in - Chief Ronald L. Van Nest, CRNA, JD Associate Editors Vicki C. Coopmans, CRNA, PhD Julie A. Pearson, CRNA, PhD EDITORIAL BOARD & SECTION EDITORS Pediatrics Janet A. Dewan, CRNA, MS Northeastern University Obstetrics Greg Nezat, CRNA, PhD Navy Nurse Corps Anesthesia Program Research & Capstone Joseph E. Pellegrini, CRNA, University of Maryland PhD Regional / Pain Christopher Oudekerk, CRNA, Uniformed Services Universi- DNP ty of the Health Sciences Cardiovascular Michele Gold, CRNA, PhD University of Southern Cali- fornia Thoracic/ Fluid Balance Lori Ann Winner, CRNA, MSN University of Pennsylvania Unique Patient Syndromes Kathleen R. Wren, CRNA, PhD Florida Hospital College of Health Sciences Equipment Carrie C. Bowman Dalley, Georgetown University CRNA, MS Pharmacology Maria Magro, CRNA, MS, University of Pennsylvania MSN Pathophysiology JoAnn Platko, CRNA, MSN University of Scranton Special Surgical Techniques Russell Lynn, CRNA, MSN University of Pennsylvania 1 Airway & Respiration Michael Rieker, CRNA, DNP Wake Forest University Baptist Medical Center ,Nurse Anesthesia Program, Univer- sity of North Carolina at Greensboro Neurology & Neurosurgery -
Tracheal Intubation Following Traumatic Injury)
CLINICAL MANAGEMENT UPDATE The Journal of TRAUMA Injury, Infection, and Critical Care Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury C. Michael Dunham, MD, Robert D. Barraco, MD, David E. Clark, MD, Brian J. Daley, MD, Frank E. Davis III, MD, Michael A. Gibbs, MD, Thomas Knuth, MD, Peter B. Letarte, MD, Fred A. Luchette, MD, Laurel Omert, MD, Leonard J. Weireter, MD, and Charles E. Wiles III, MD for the EAST Practice Management Guidelines Work Group J Trauma. 2003;55:162–179. REFERRALS TO THE EAST WEB SITE and impaired laryngeal reflexes are nonhypercarbic hypox- Because of the large size of the guidelines, specific emia and aspiration, respectively. Airway obstruction can sections have been deleted from this article, but are available occur with cervical spine injury, severe cognitive impairment on the Eastern Association for the Surgery of Trauma (EAST) (Glasgow Coma Scale [GCS] score Յ 8), severe neck injury, Web site (www.east.org/trauma practice guidelines/Emergency severe maxillofacial injury, or smoke inhalation. Hypoventi- Tracheal Intubation Following Traumatic Injury). lation can be found with airway obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal cord injury. I. STATEMENT OF THE PROBLEM Aspiration is likely to occur with cardiac arrest, severe cog- ypoxia and obstruction of the airway are linked to nitive impairment, or severe maxillofacial injury. A major preventable and potentially preventable acute trauma clinical concern with thoracic injury is the development of Hdeaths.1–4 There is substantial documentation that hyp- nonhypercarbic hypoxemia. Lung injury and nonhypercarbic oxia is common in severe brain injury and worsens neuro- hypoxemia are also potential sequelae of aspiration. -
Authors Conducted an E-Mail Survey of Anesthesiologists in the US in 2010
Appendix 2: Reference 1 Methods: Authors conducted an e-mail survey of Anesthesiologists in the US in 2010. Results: “Five thousand anesthesiologists were solicited; 615 (12.3%) responses were received. Twenty-four percent of respondents had installed an AIMS, while 13% were either installing a system now or had selected one, and an additional 13% were actively searching. Larger anesthesiology groups with large case loads, urban settings, and government affiliated or academic institutions were more likely to have adopted AIMS. Initial cost was the most frequently cited AIMS barrier. The most commonly cited benefit was more accurate clinical documentation (79%), while unanticipated need for ongoing information technology support (49%) and difficult integration of AIMS with an existing EMR (61%) were the most commonly cited problems.” [Trentman TL, Mueller JT, Ruskin KJ, Noble BN, Doyle CA. Adoption of anesthesia information management systems by US anesthesiologists. J Clin Monit Comput 2011;25:129–35.] Reference 2 Joint Commission Report. 60 [Kohn L, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Report from the Committee on Quality of Health Care in America. Washington DC: The Joint Commission journal on quality improvement, 1999:227–34.] Reference 3 Excerpt: “The Department of Health and Human Services (DHHS) released two proposed regulations affecting HIT (www.healthit.hhs.gov). The first, a notice of proposed rule- making (NPRM), describes how hospitals, physicians, and other health care professionals can qualify for billions of dollars of extra Medicare and Medicaid payments through the meaningful use of electronic health records (EHRs). The second, an interim final regulation, describes the standards and certification criteria that those EHRs must meet for their users to collect the payments. -
Statement on Safe Use of Propofol 2019
Statement on Safe Use of Propofol Committee of Origin: Ambulatory Surgical Care (Approved by the ASA House of Delegates on October 27, 2004, and amended on October 23, 2019) Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonist medications, agents such as propofol require special attention. Even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation. The Society believes that the involvement of an anesthesiologist in the care of every patient undergoing anesthesia is optimal. However, when this is not possible, non-anesthesia personnel who administer propofol should be qualified to rescue* patients whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anesthesia.** • The physician responsible for the use of sedation/anesthesia should have the education and training to manage the potential medical complications of sedation/anesthesia. The physician should be proficient in airway management, have advanced life support skills appropriate for the patient population, and understand the pharmacology of the drugs used. The physician should be physically present throughout the sedation and remain immediately available until the patient is medically discharged from the post procedure recovery area. • The practitioner administering propofol for sedation/anesthesia should, at a minimum, have the education and training to identify and manage the airway and cardiovascular changes which occur in a patient who enters a state of general anesthesia, as well as the ability to assist in the management of complications. -
Intravenous Sedation and Preparing for Your Procedure
Oral and Maxillofacial Surgery Intravenous sedation and preparing for your procedure Information for patients Please ensure that you read this leaflet before you come to hospital for your operation What is sedation? Sedation is a way of using drugs (sedatives) to make you feel relaxed and sleepy during your procedure. We will give you your sedatives through an injection into a vein. Sedation is not a general anaesthetic and you will not be unconscious. You may not remember much of what happens during the procedure and directly afterwards. This is quite normal. Local anaesthetic will be given once you have been sedated. Do not drive, operate machinery or sign important documents for at least 24 hours after your procedure. You must make sure that you have a responsible adult with you who can stay in the department for a couple of hours and take you home by car or taxi. Someone must also stay with you for at least 24 hours after your procedure. Your procedure will be cancelled if you do not bring someone with you who can do this. Preparation for your procedure and what to bring with you • Patients having a procedure under sedation must follow the current fasting guidelines for general anaesthesia. You must not eat or drink for 6 hours before your procedure but you may have water up to 2 hours before. If you do eat or drink after these times your surgery will be cancelled. • Avoid alcohol for 24 hours before your procedure. • Bring with you a list of any medication or drugs you are taking. -
Femoral and Sciatic Nerve Blocks for Total Knee Replacement in an Obese Patient with a Previous History of Failed Endotracheal Intubation −A Case Report−
Anesth Pain Med 2011; 6: 270~274 ■Case Report■ Femoral and sciatic nerve blocks for total knee replacement in an obese patient with a previous history of failed endotracheal intubation −A case report− Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea Jong Hae Kim, Woon Seok Roh, Jin Yong Jung, Seok Young Song, Jung Eun Kim, and Baek Jin Kim Peripheral nerve block has frequently been used as an alternative are situations in which spinal or epidural anesthesia cannot be to epidural analgesia for postoperative pain control in patients conducted, such as coagulation disturbances, sepsis, local undergoing total knee replacement. However, there are few reports infection, immune deficiency, severe spinal deformity, severe demonstrating that the combination of femoral and sciatic nerve blocks (FSNBs) can provide adequate analgesia and muscle decompensated hypovolemia and shock. Moreover, factors relaxation during total knee replacement. We experienced a case associated with technically difficult neuraxial blocks influence of successful FSNBs for a total knee replacement in a 66 year-old the anesthesiologist’s decision to perform the procedure [1]. In female patient who had a previous cancelled surgery due to a failed tracheal intubation followed by a difficult mask ventilation for 50 these cases, peripheral nerve block can provide a good solution minutes, 3 days before these blocks. FSNBs were performed with for operations on a lower extremity. The combination of 50 ml of 1.5% mepivacaine because she had conditions precluding femoral and sciatic nerve blocks (FSNBs) has frequently been neuraxial blocks including a long distance from the skin to the used for postoperative pain control after total knee replacement epidural space related to a high body mass index and nonpalpable lumbar spinous processes. -
Moderate Sedation Study Guide 11-17-10
PROCEDURE RELATED SEDATION Outline I Introduction II Definitions: The 5 Levels of Sedation and Anesthesia III Emergency Procedures, Critical Care Areas and Policy Exclusions IV The Pre-Sedation Assessment V NPO: The Timing of Eating and Drinking before Sedation VI Review of Some Agents Used for Sedation VII Orders for Procedure Related Sedation VIII Environmental Requirements and Monitoring During Sedation IX Post-Procedure Monitoring and the PAR Score X Discharge Criteria and Concluding Post-Procedure Monitoring 1 PROCEDURE RELATED SEDATION Lance Brown, MD, MPH I. Introduction The purpose of this tutorial is to familiarize the reader with the Loma Linda University Medical Center Policy M-86 for Procedure Related Sedation. Procedure related sedation is used to make necessary medical procedures as comfortable as possible for patients and to facilitate the performance of necessary medical procedures by health care providers (typically physicians). It is important for health care providers performing procedure related sedation to be familiar with the pharmacologic characteristics of the agents being used, to understand the risk factors for complications related to procedure related sedation, and to individually plan the sedation for each patient. Each health care practitioner privileged to provide procedure related sedation takes responsibility for both the comfort and safety of the patients in their care. II. Definitions At Loma Linda University Medical Center, we have defined five distinct levels of sedation and anesthesia. Familiarity with the definitions of these levels of sedation is important for safely providing procedure related sedation and for complying with the policy of the Medical Center. It must be recognized, however, that sedation occurs along a continuum and that individual patients may have different degrees of sedation for a given dose and route of medication. -
Dexmedetomidine During Suprazygomatic Maxillary Nerve Block for Pediatric Cleft Palate Repair, Randomized Double-Blind Controlled Study Mohamed F
Korean J Pain 2020;33(1):81-89 https://doi.org/10.3344/kjp.2020.33.1.81 pISSN 2005-9159 eISSN 2093-0569 Original Article Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study Mohamed F. Mostafa1, Fatma A. Abdel Aal1, Ibrahim Hassan Ali1, Ahmed K. Ibrahim2, and Ragaa Herdan1 1Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt 2Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt Received July 26, 2019 Revised December 3, 2019 Background: For children with cleft palates, surgeries at a young age are necessary Accepted December 3, 2019 to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedeto- Correspondence midine might prolong the postoperative analgesic duration when added to bupiva- Mohamed F. Mostafa caine during nerve blocks. Department of Anesthesia and Intensive Methods: Eighty patients of 1-5 years old were arbitrarily assigned to two equal Care, Assiut University Hospital, Faculty groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve of Medicine, Assiut University, Assiut blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum vol- 71515, Egypt Tel: +20-1001123062 ume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 Fax: +20-88-2333327 μg/kg dexmedetomidine (maximum volume 4 mL/side). E-mail: [email protected] Results: The modified children’s hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). -
Moderate Sedation
MODERATE SEDATION A SELF STUDY GUIDE Part I Self Study Guide Part II ASA Practice Guidelines for Sedation And Analgesia by Non-Anesthesiologists Part III Sedation/Analgesia Policy 1 Introduction Diagnostic and surgical procedures are being performed in a variety of settings throughout the hospital. This self-study program has been developed to increase your awareness and reinforce your understanding of the use of moderate sedation. It includes indications/contraindications for moderate sedation, accepted medications administration guidelines, and monitoring requirements. Part I is dedicated to an overall review of the principles of moderate sedation, Part II includes the American Society of Anesthesiology’s Practice Guidelines For Sedation And Analgesia by Non- Anesthesiologist. Part 3 is a post-test. Completion of this self-study packet includes learning the following material, satisfactory completion of the post-test and returning the post-test to the Medical Staff Office. Completion of this self-study is required to qualify for privileges to administer Moderate Sedation at St. David’s Medical Center. Purpose The purpose of this self-study packet is to increase and reinforce your knowledge of responsibilities and guidelines associated with the care of individuals requiring moderate sedation. On completion of this self-study program, you should be able to: 1. Recognize indications and contraindication for moderate sedation. 2. State appropriate monitoring techniques and requirements for patients undergoing moderate sedation. 3. Identify medications frequently used for moderate sedation, administration guidelines, and potential complications/side-effects. 4. Evaluate and manage expected and unexpected outcomes of moderate sedation Part I Definition Conscious Sedation more accurately termed Sedation/Analgesia or Moderate Sedation describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal commands and tactile stimulation. -
Northwest Arkansas Regional Ems Protocols
Regional Protocol PROTOCOL SECTION NORTHWEST ARKANSAS REGIONAL EMS PROTOCOLS 2019 REVISION 2019 a Regional Protocol PROTOCOL SECTION TABLE OF CONTENTS……………………………………………………………………………….b - e INTRODUCTORY STATEMENT………………......……………………………………………….........f PARTICIPATING AGENCIES………………………………………………………………………….…………..g 2019 DEPARTMENT MEDICAL DIRECTORS & SIGNATURE………………..…………………………........h SECTION ONE - PROTOCOLS GENERAL PROTOCOLS UNIVERSAL PATIENT CARE ................................................................................................................... 1 CHEMICAL EXPOSURE (HAZMAT) ......................................................................................................... 2 CHEMICAL SEDATION FOR VIOLENT PATIENT .................................................................................... 3 PAIN MANAGEMENT ............................................................................................................................... 4 SPINAL RESTRICTION ............................................................................................................................ 5 VASCULAR ACCESS ............................................................................................................................... 6 RESPIRATORY OXYGEN ADMINISTRATION……….…………………………………………………………..…………………..7 GENERAL AIRWAY MANAGEMENT………………….……………………………………..…………………….8 ADVANCED AIRWAY MANAGEMENT….……………………………………………………..…………………..9 PHARMACOLOGICAL ASSISTED INTUBATION (PAI)………………….……………………………………..10 ALLERGIC REACTION—ANAPHYLAXIS….……………………………………………………………………..11 -
Progressive Mandibular Midline Deviation After Difficult Tracheal
Anaesthesia 2013 doi:10.1111/anae.12271 Case Report Progressive mandibular midline deviation after difficult tracheal intubation J. Mareque Bueno,1,2 M. Fernandez-Barriales,3 M. A. Morey-Mas4,5 and F. Hernandez-Alfaro6,7 1 Associate Professor, 6 Professor, Department of Oral and Maxillofacial Surgery, Universitat Internacional de Catalunya, Barcelona, Spain 2 Staff, 3 Visiting Resident, 7 Director, Institute of Maxillofacial Surgery, Teknon Medical Center, Barcelona, Spain 4 Staff, Department of Oral and Maxillofacial Surgery, Hospital Son Dureta, Palma de Mallorca, Illes Balears, Spain 5 Associate Professor, Especialidad Universitaria en Implantologıa Oral, Universitat des Illes Balears, Illes Balears, Spain Summary We report condylar resorption of the temporomandibular joint after difficult intubation, leading to progressive midline mandibular deviation, subsequently treated by prosthetic joint replacement. ................................................................................................................................................................. Correspondence to: M. Fernandez-Barriales Email: [email protected] Accepted: 19 March 2013 Forces applied during difficult tracheal intubations can Following induction of anaesthesia and neuromus- cause oedema, bleeding, tracheal and oesophageal per- cular blockade, laryngoscopy with a Macintosh blade foration, pneumothorax or aspiration. Resorption of (size 3) permitted revealed a poor laryngeal view the temporomandibular joint has not been associated (Cormack-Lehane