Anesthesiology and Intensive Care

Acute restoration of sinus rhythm. Cardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract effectively.    During cardiopulmonary resuscitation (CPR) it is obligatorily to recognize Shockable or Non-Shockable the heart rhythm. It is important to know when to use defibrillation.

         As an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema.      Its beta-receptor  activity dilates the bronchial airways, increases the force of myocardial contraction, and suppresses histamine and leukotriene release.      There are also beta-2 adrenergic receptors on mast cells that inhibit activation, and so early adrenaline attenuates the severity of IgE-mediated allergic reactions. 

Common etiologies of fever of unknown origin:

     Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction.     Incidence rate : 30 - 950 cases per 100,000 persons per year. It is important to note that, in many cases, no cause can be identified. A significant number of cases of anaphylaxis are idiopathic (non-IgE mediated).  Anaphylaxis is likely when all of the following 3 criteria are met:

    Peripheral Nerve Stimulation is the most common method used to identify nerves percutaneously. Pure ulnar/radial/median nerve stimulation can only be achieved at the axilla or below. Indicates motor supply of the nerve. Sensory stimulation can be  achieved with some peripheral nerve stimulators. Patient cooperation is desirable but not essential—sedation or GA is possible, but the patient should not have received neuromuscular  blocking drugs. Possible reduced potential for nerve damage, because there is no need for direct physical contact with the nerve (paresthesia). Usually comfortable for the patient.

The  abbreviated mental test score  ( AMTS ) is  used in  medicine  to assess for  confusion  and other cognitive impairment, although it has mainly been validated in the elderly. The following questions are put to the patient. Each question correctly answered scores one point. A score of 7-8 or less suggests cognitive impairment at the time of testing, although further and more formal tests are necessary to confirm a diagnosis of dementia, delirium or other causes of cognitive impairment.

         TURP (t ransurethral resection of the prostate)  syndrome - it is a combination of fluid overload and hyponatremia, which occurs when large volumes of irrigation fluid are absorbed via open venous sinuses. The most commonly used irrigant is glycine 1.5% in water, which is hypotonic (osmolality 220 mosm/L). On average, patients absorb a total of 1–1.5 L, but absorption of up to 4–5 L can be possible.

        The global prevalence of opiate (heroin and opium) use was estimated at 0.4% of the population, or 12.8-20.2 million people (  the  United Nations Office on Drug and Crime (UNODC) ).   F rom 2004 to 2011 medical use of opioids increased 100%; use of codeine decreased 20% ( ARCOS ). Receptors and main effects of opioids:

In case of    Right Bundle Branch Block a ctivation of right  ventricle  is delayed and spreads through the septum from the left side (left ventricle). Blockade location, both in complete and partial blocks, is usually proximal. Main causes: Pulmonary embolism Chronic obstructive lung disease. Ischaemic heart disease (myocardial infarction) Hypertensive heart disease Myocarditis Cardiomyopathy RBBB also can occur in normal individuals without underlying heart disease ECG criteria:

     About 20% of patients redevelop symptoms of Malignant Hyperthermia. The mean time until symptoms redeveloped was 13 hours, with a range of 2.5 to 72 hours. (data from the NAMHR)     Dantrolene pretreatment is no longer indicated. Dantrolene pretreatment may cause mild weakness in normal patients and significant weakness in patients with muscle disorders.     The gold  standard for diagnosis is the caffeine-halothane contracture test (CHCT). The patient’s  muscle is exposed to incremental doses of halothane and caffeine, and the muscle is  evaluated for the degree of contracture. Using this test is very limited. Preparations for  Malignant Hyperthermia-susceptible patients:

Cardiac output is the amount of blood  being pumped by the  heart  in 1 minute.   Thus the  equation  is:  Cardiac Output = Stroke volume * Heart Rate

     Transesophageal Echocardiography (TEE) is often  performed by a cardiac anesthesiologist to evaluate, diagnose, and treat patients in the perioperative period. TEE is very useful during many cardiac surgical procedures (e.g., mitral valve repair, off-pump and on-pump CABG).  It helps to detect and quantify the disease preoperatively as well as to assess the results of surgery immediately after the procedure.  If the repair is found to be inadequate,

     The step-by-step standardization of TOP-MINI provides an effective tool among the available minimally invasive MVR techniques. This procedure is feasible and highly reproducible with significant clinical results. It does not require any structural change to the dynamics of the operating room or cardiac surgery team. The TOP-MINI procedure does indeed push the boundaries of minimally invasive MVR techniques to a new level.

This article is based on  "Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology". The decision to use a particular anesthetic technique for cesarean delivery should be individualized, based on anesthetic, obstetric, or fetal risk factors (e.g., elective vs. emergency), the preferences of the patient, and the judgment of the anesthesiologist. Uterine displacement  (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used. ( effective approach to managing hypotension as it helps in directly relieving the aortocaval compression ) Consider selecting  neuraxial techniques  in preference to general anesthesia (GA) for most cesarean deliveries. ( higher Apgar scores at 1 and 5 min for epidural anesthesia when compared with GA.  When spinal anest

Optimal positioning for obese patients with a short neck (especially in obstetrics) is the main predictor of successful intubation.  Potential difficulty in securing the airway in pregnant patients may be due to: airway edema a full dentition large breasts that can obstruct the handle of the laryngoscope in patients with short necks increased intra- abdominal   pressure High risk of regurgitation of gastric contents and acid aspiration syndrome Rapid onset of hypoxaemia after induction ( FRC reduced by 20% ) Risk of bleeding from airway manipulation due to coagulopathy in pre-eclampsia.

     Laryngospasm is the most common cause of post-extubation upper airway obstruction.This may present as mild inspiratory stridor or complete airway obstruction.   It is more common in children undergoing upper airway surgery. Laryngospasm is most frequently caused by local irritation by blood or saliva and is likely to occur in patients during light planes of anaesthesia, when they are neither able to prevent this reflex nor generate an adequate cough. In children, the incidence can be reduced if they are left undisturbed in the lateral recovery position until they wake up.    I.V. magnesium (15 mg kg −1  over 20 min) and lidocaine (1.5 mg kg −1 ) have been used to prevent laryngospasm. Table  describes a management plan for established laryngospasm:

''Respiratory complications after tracheal extubation are three times more common than complications occurring during tracheal intubation and induction of anaesthesia (4.6%  vs  12.6%).

CHICAGO – Children who are exposed to general anesthesia from birth to age 2 have developmental testing results in kindergarten that are similar to those of children who have not been exposed, according to a new study published in the October issue of  Anesthesiology , the official medical journal of the  American Society of Anesthesiologists  (ASA).

The score is an acronym for each of the risk factors measured. Each risk factor scores one point, for a maximum score of 5:

Before starting treatment of   community-acquired pneumonia check the CURB-65 score    (click the link to discover more) : 0–1 home treatment possible;  2 hospital therapy;  ≥3 severe pneumonia (indicates mortality 15–40%—consider Intensive Care Unit).

read also:   Acute Kidney Injury. Causes and Differential Diagnosis. Some agents can be used safely ( cyan color of the table cells)

Read also:   Anesthetic agents and impaired renal function. Acute kidney injury (AKI) is defined as an abrupt or rapid loss in kidney filtration function,    that develops within 7 days.   Main groups of causes are: I     PRERENAL Absolute decrease in effective blood volume Severe blood loss Volume depletion Severe burns Relative decrease in blood volume (ineffective arterial volume) Congestive heart failure Decompensated liver cirrhosis Arterial occlusion or stenosis of renal artery Hemodynamic form NSAIDs ACE inhibitor or angiotensin-II receptor antagonists in renal-artery stenosis or congesitve heart failure II   INTRINSIC RENAL   Vascular Vasculitis, malignant hypertension Acute glomerulonephritis Postinfectious glomeronephritis disease caused by antibody to glomerular basement membrane Acute tubular necrosis  Acute interstitial nephritis Ischemic Nephrotoxic Exogenous: Antibiotics (gentamicin), Radio contrast agents, Cisp

WHAT DO THE TERMS MEANS  - INOTROPIC, BATHMOTROPIC, DROMOTROPIC, CHRONOTROPIC AND LUSITROPIC... click to enlarge: SIGN UP!

Emergency Treatment for An Acute MH Event READ ALSO:  Malignant hyperthermia: Causes and Clinical Manifestations The following four things should be done as soon as possible: Notify surgeon to halt the procedure ASAP( as  soon  as possible ): Discontinue volatile agents and succinylcholine.

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Malignant hyperthermia (MH) is a rare life-threatening genetic hypermetabolic muscle disease, signs and symptoms of which most commonly triggered with exposure to inhaled general anesthetics or succinylcholine.  Epidemiology: 1:15,000 in pediatric patients and 1:40,000 adult patients.

Right Ventricular Hypertrophy is an increase in the thickness of the walls of the right ventricle. The right ventricle is three times thinner than the left ventricle, thus frequently hypertrophy of the right ventricle may be unrecognized. Causes:

Larry Hand NEW ORLEANS, LA — Among intermediate-surgical-risk patients with aortic stenosis in a German registry, adjusted mortality at 1 year was significantly higher for those undergoing transcatheter aortic valve implantation (TAVI) compared to surgical aortic-valve replacement (SAVR), in a study presented here at the  American Heart Association (AHA) 2016 Scientific Sessions [1] .

This new approach for the treatment of symptomatic patients with severe aortic stenosis (AS) has been shown to be feasible and safe in patients at very high or prohibitive surgical risk.  The following are indications for Aortic Valve Replacement (AVR) for severe Aortic Stenosis that apply to either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI):

The Transcatheter Aortic Valve Replacement (TAVR) procedure offers hope for heart patients with inoperable aortic stenosis (failing heart valves). TAVR valves are inserted via a catheter through the femoral artery, without requiring open heart surgery. 

Brain injury is a major source of patient morbidity after cardiac surgery and is associated with prolonged hospitalization, excessive operative mortality, high hospital costs, and altered quality of life. Main reasons: cerebral embolism by air, fat, atheromatous debris, thrombus (micro- or macroemboli) 50% of strokes; hypoperfusion inflammatory processes evoked from CPB and/or ischemia/reperfusion injury; Clinical forms of brain injury and relative frequencies: Clinical manifestation Frequency Stroke   Low risk patient ≤ 1%   High risk patient 5% to 16% Encephalopathy 8.4% to 32% Neurocognitive dysfunction   Hospital discharge 40% to 75%   One Month after surgery 12% to 30% Recommendations for measures to protect brain injury during cardiac surgery: see more:  Brain Protection in Cardiac Surgery

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 It's hard to make decision about reexporation after cardiac surgery. This table helps to identify acceptable blood loss.  But it's more difficult to divide "surgical" (from blood vessel) and "anesthetic" (coagulopathic) blood loss 😀

There are three types of coronary dominance. It depends on what coronary  artery supplies the   posterior descending artery . It can be estimated angiographically. First, h ave a look at the coronary anatomy. P osterior descending artery is written in red color. "RIGHT-DOMINANT" (70% of population): posterior descending artery is supplied by the right coronary artery ; "LEFT-DOMINANT" (10% of population):  posterior descending artery is supplied by the circumflex artery , a branch of the left artery; "CO-DOMINANT" (20% of population):   posterior descending artery is supplied by both the right coronary artery and the circumflex artery.        Dominance has important implications in  myocardial ischaemia and infarction.        The tissue separating the right and left ventricles of your heart (the interventricular septum) receives blood predominantly from the left coronary artery, but the exact breakdown of blood source is deter

The laryngeal mask airway (LMA) is an acceptable alternative to mask anesthesia in the operating room. It is often used for short procedures when endotracheal intubation is not necessary.   Here some important steps for successful insertion of LMA   (click to enlarge) : Relative contraindications for the LMA: patients with pharyngeal pathology (eg, abscess) pharyngeal obstruction full stomachs (eg, pregnancy,hiatal hernia) low pulmonary compliance (eg, restrictive airways disease) requiring peak inspiratory pressures greater than 30 cm H2O.

    Sevoflurane used as an inhalational (volatile) anaesthetic for induction and maintenance of general anesthesia. Sevoflurane acts as a positive allosteric modulator of the GABAA receptor and an NMDA receptor antagonist .

Do not ignore physical examination of your patient. It's interesting. For example, today's case: about 70 years old male, CABG procedure. What symptom do you see? Answer is under the spoiler ) ANSWER : Arcus senilis (or arcus senilis corneae) is a white, grey, or blue opaque ring in the corneal margin (peripheral corneal opacity), or white ring in front of the periphery of the iris. It is present at birth but then fades; however, it is quite commonly present in the elderly. It can also appear earlier in life as a result of hypercholesterolemia So it is sign of diffuse atherosclerosis .

And good nurse will manage it easily!

Table of risk factors for postoperative pulmonary complications. Click to enlarge: ASA, American Society of Anesthesiologists. 1. Within each evidence category, risk factors are listed according to  strength of evidence, with the first factor listed having the strongest evidence. 2. Subsequent evidence indicates that this is a probable risk factor. Data from Smetana GW, Lawrence VA, Cornell JE, et al: Preoperative  pulmonary risk stratifi cation for noncardiothoracic surgery: systematic  review for the American College of Physicians, Ann Intern Med  2006;144(8):581-595.