Anesthesiology and Intensive Care

Angina pectoris , commonly known as  angina , is the sensation of  chest pain , pressure, or squeezing, often due to  ischemia  of the  heart muscle  from  obstruction  or  spasm  of the  coronary arteries .   Classification of Angina Severity  according to the Canadian Cardiovascular Society a Equivalent to 100–200 m.

Different clinical scenarios lend themselves to the use of certain induction agents when rapid sequence intubation (RSI) is needed. Head injury or stroke   —  In the patient with potentially elevated intracranial pressure (ICP) from head injury or stroke or other conditions, adequate cerebral perfusion pressure must be maintained to prevent secondary brain injury. This means avoiding elevations in ICP and maintaining adequate mean arterial pressure. For these reasons, etomidate or ketamine are used for induction of these patients. If the patient is hypertensive at the time of induction, etomidate is preferable, as it will not further elevate the blood pressure. In normotensive or hypotensive patients, either agent can be used. In the severely hypotensive patient, ketamine is preferable. Ketamine's analgesic effects minimize the adverse sympathetic stimulation of laryngoscopy, while etomidate lacks such effect. Pretreatment with a low dose of  fentanyl  (3  mcg/

a. Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (e.g., LMA(laryngeal mask), ILMA (intubating  laryngeal mask ), laryngeal tube), local anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway. b. Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation. c. Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (e.g., LMA or ILMA) as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and blind oral or nasal intubation. d. Consider re-preparation of the patient for awake in

The test comprises a visual assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space in which there is to work. It is an indirect way of assessing how difficult an intubation will be. Original Mallampati Scoring contains 3 classes, but nowadays we are using 4 classes   Modified Mallampati Scoring : Class I: Soft palate, uvula, fauces, pillars visible. Class II: Soft palate, uvula, fauces visible. Class III: Soft palate, base of uvula visible. Class IV: Only hard palate visible. The Cormack-Lehane system classifies views obtained by direct  laryngoscopy  based on the structures seen. CL grades 1 ( A ), 2 ( B ), 3 ( C ), and 4 ( D ) in the SimMan TM  human patient simulator. a, laryngoscope blade; b, epiglottis; c, glottic opening; d, arytenoid cartilages. According to the original definition by Cormack and Lehane, most of the glottic opening can be seen with grade 1. In grade 2, only the pos

    ASA PS Classification Definition Adult Examples, Including, but not Limited to: Pediatric Examples, Including but not Limited to: Obstetric Examples, Including but not Limited to: ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use Healthy (no acute or chronic disease), normal BMI percentile for age   ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations Normal pregnancy*, well controlled gestational HTN, controlled preeclampsia without severe features, diet-controlled gestational DM. ASA III A patient with

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NSAIDs can exacerbate HF by promoting sodium and water retention, higher intravascular resistance, and reduced response to diuretics. Whenever possible, NSAIDs should be avoided among patients with HF. Thiazolidinediones can exacerbate existing HF and promote new HF. The risk for HF complications appears to be stronger with rosiglitazone vs pioglitazone. The dipeptidyl peptidase-4 (DPP-4) inhibitors are also associated with an increased risk for HF exacerbation, with an odds ratio of 1.19 in one meta-analysis. In contrast, metformin has been associated with reduced mortality risk among patients with HF in recent studies. However, metformin still should be avoided among patients with moderate or severe chronic kidney disease. Treatment with doxazosin was associated with a 2-fold increase in incident HF compared with treatment with chlorthalidone in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Amlodipine does not reduce mortality r

Ischemic Heart Disease Patients with low Mg levels have a higher risk of coronary artery disease. High Mg levels are associated with a reduced cardiovascular disease and mortality. This inverse association between Mg levels and coronary artery disease has been noted both in women and men. Low Mg levels have also been implicated in major adverse events following drug-eluting stent  implantation . Mg levels are frequently low after cardiac surgery and may play a role in the development of post-operative arrhythmias. Hypomagnesemia with Mg <  2 mEq/L or less is also associated with increased mortality in ambulatory heart failure patents. The main pathology in ischemic heart disease is atherosclerosis, and Mg deficiency may exacerbate this process. Epidemiological studies have found a direct correlation between low Mg levels and atherosclerosis. Hypomagnesemia also adversely affects lipid metabolism and C-reactive protein. Both of these abnormalities have deleterious effects on e

    Here is brief information and the most important conclusions. To read original article, click this link The internal mammary arteries (IMAs) are commonly used as the conduit to bypass major coronary artery stenosis, and have shown greater long-term patency rates and improved survival as compared to saphenous vein grafts (SVGs). The internal mammary artery (IMA) grafts have been associated with long-term patency and improved survival as compared to saphenous vein grafts (SVGs).      The superiority of IMAs over SVGs can be attributed to its striking resistance to the development of atherosclerosis. Structurally its endothelial layer shows fewer fenestrations, lower intercellular junction permeability, greater anti-thrombotic molecules such as heparin sulfate and tissue plasminogen activator, and higher endothelial nitric oxide production , which are some of the unique ways that make the IMA impervious to the transfer of lipoproteins, which are responsible for the develop

Demonstration of ITA harvesting with explaining and advices

1. Use the Table below or Link to calculate Stroke Risk CHA2DS2-VASc Score for Atrial Fibrillation Stroke Risk 2.Stroke prevention Algorithm AF          atrial fibrillation NOAC     non-vitamin K antagonist oral anticoagulant OAC       oral anticoagulation/oral anticoagulant LAA         left atrial appendage a             Congestive heart failure, Hypertension, Age ≥75 years (2 points), Diabetes,     prior Stroke/TIA/embolus (2 points), Vascular disease, age 65–74 years, femaleSex. b             Includes women without other stroke risk factors. c             IIaB for women with only one additional stroke risk factor. d             IB for patients with mechanical heart valves or mitral stenosis. According with 2016 ESC Guidelines for the management of atrial  fibrillation

Conclusions of some studies that investigated e ffect of ketamine on bispectral index (BIS). Effect of ketamine on bispectral index during propofol--fentanyl anesthesia: a randomized controlled study.  Sengupta S ,  Ghosh S ,  Rudra A ,  Kumar P ,  Maitra G ,  Das T .                 Click to read more from source CONCLUSION : Thus, under stable propofol anesthesia, a bolus of  KETAMINE 0.5 MG/KG INCREASES BIS VALUES WHILE KETAMINE 0.2 MG/KG DOES NOT.                         Comparative effects of ketamine on Bispectral Index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia   P.Hans, P.-Y. Dewandre ,  J. F. Brichant  and  V. Bonhomme Click to read more from source Conclusions.  Ketamine administered under sevoflurane anaesthesia causes a  significant increase in BIS, RE and SE without modification of the RE–SE gradient. This increase is paradoxical in that it is associated with a deepening level of hypnosis.  

    Ketamine is a unique anesthetic drug that provides analgesia, hypnosis, and amnesia with minimal respiratory and cardiovascular depression.  Ketamine produces a unique cataleptic trance known as disassociative anesthesia.     Dissociative anesthesia is a unique anesthesia characterized by analgesia and amnesia with minimal effect on respiratory function. The patient does not appear to be anesthesized and can swallow and open eyes but does not process information.     Ketamine was first tested in humans at the Parke Davis Research Unit of Jackson Prison in Michigan. The first human received the drug on August 3, 1964. By 1970, it was approved as an anesthetic agent by the US FDA. Advantages and Precautions Ketamine induces significant increases in HR, mean arterial pressure, and plasma epinephrine levels. This sympathetic nervous system stimulation is centrally mediated.  It can be harmful in patients with stenotic heart lesions or coronary artery disease.  K

The distinction between paroxysmal and persistent AF is often not made correctly  without access to long-term monitoring. Hence, this classification alone is often  insufficient to select specific therapies.  If both persistent and paroxysmal episodes  are present, th e predominant pattern should guide the classification . According with 2016 ESC Guidelines for the management of atrial  fibrillation

CI = cardiac index HB = hemoglobin SaO2 = arterial oxygen saturation PaO2 = partial pressure of oxygen in arterial blood SvO2 = venous oxygen saturation PvO2 = partial pressure of oxygen in venous blood Oxygen delivery and consumption calculations should be utilised to evaluate and optimize gas exchange

The causes  of Diabetic Ketoacidosis  can be remembered using acronym  MUDPILES   Causes of raised anion gap  metabolic acidosis indicate the presence of an unmeasured anion. The anion gap can be calculated as follows: (Na+ + K+) – (HCO3– + Cl–) Normal range: 8–16 mmol/L

STATEMENT ON STANDARD PRACTICE FOR INFECTION PREVENTION AND CONTROL INSTRUMENTS FOR TRACHEAL INTUBATION  Committee of Origin: Committee on Quality Management and Departmental Administration (QMDA(Approved by the ASA House of Delegates on October 20, 2010, and last amended  on October 28, 2015)  Statement : All instruments used for intubation of the trachea (endotracheal tubes, laryngeal mask airways (LMAs), laryngoscopes, fiberoptic devices, stylets, forceps, or other airway devices) should be properly cleaned using standard methods for decontamination and high-level disinfection between each patient use and stored in a clean environment. Sterility is not required . Prepackaged endotracheal tubes can be opened, cuffs checked for any leaks, stylets placed for future use, cuff syringes attached, and placed back into the package. Data suggest that storage and subsequent use of such prepared endotracheal tubes is reasonable for up to 48 hours.   Rationale : The mouth (whe

Amazing Demonstration of Arterial Line Placement INDICATIONS: Continuous direct BP monitoring Inability to use indirect BP monitoring (eg, in patients with severe burns or morbid obesity) Frequent blood sampling Frequent arterial blood gas sampling CONTRAINDICATIONS: Absent pulse Thromboangiitis obliterans (Buerger disease) Full-thickness burns over the cannulation site, infection Inadequate circulation to the extremity Raynaud syndrome Synthetic vascular graft COMPLICATIONS: Temporary radial artery occlusion (19.7%) Hematoma/bleeding (14.4%) Localized catheter site infection (0.72%) - The risk increases with the length of time the catheter is in place  Hemorrhage (0.53%) Sepsis (0.13%) Permanent ischemic damage (0.09%) Pseudoaneurysm formation (0.09%) Thrombosis Arteriovenous fistula Air embolism Compartment syndrome Carpal tunnel syndrome Paralysis of median nerve