Anesthesiology and Intensive Care

    Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity  reaction. The estimated incidence of perioperative anaphylaxis is 1 in 10,000– 20,000 anesthetic procedures.

          Nonsteroidal anti-inflammatory agents (NSAIDs) are widely used for treatment of mild to moderate pain in children. These agents are particularly useful for supplementation of analgesia with regional/local anesthesia techniques.  Agents used commonly in children are:

Drugs for Cesarean Delivery & Duration of Surgical Anesthesia:

    What is new in 2017 STEMI Guidelines. BMS = bare metal stent; DES = drug eluting stent; IRA = infarct related artery; i.v. = intravenous; LDL = low-density lipoprotein; PCI = percutaneous coronary intervention; SaO2 = arterial oxygen saturation; STEMI = ST-elevation myocardial infarction; TNK-tPA = Tenecteplase tissue plasminogen activator.

1.  Patients with dehydration, hypovolemia or who have impaired renal  function are at increased risk for decreasing renal function or renal  failure.

     Serum marker sensitivity relative to the time of onset of chest pain in the patient with acute myocardial infarction (AMI):

         The muscarinic antagonists compete with neurally released acetylcholine ( ACh )   for access to muscarinic cholinoceptors and block  ACh’s  effects. The results are faster heart rate, sedation,  and dry mouth. With the exception of the quaternary  ammonium compounds that do not readily cross the  blood-brain barrier and have few actions on the CNS,  there is no significant specificity of action among these drugs; they block all muscarinic effects with equal efficacy, although there are some quantitative differences in effect.

              Pain is often the patient’s presenting symptom.  It can provide useful clinical information and it is your responsibility to use this information to help the patient and alleviate suffering.     Manage pain wherever you see patients (emergency, operating room and on the ward) and anticipate their needs for pain management after surgery and discharge.  Do not unnecessarily delay the treatment of pain; for example, do not transport a patient without analgesia simply so that the next practitioner can appreciate how much pain the patient is experiencing.

  According to   Guidelines from the European Society of Anaesthesiology Cardiovascular surgery:

Class I: Fast sodium (Na) channel blockers:  Ia - Quinidine, procainamide, disopyramide (depress phase 0, prolonging repolarization)  Ib - Lidocaine, phenytoin, mexiletine (depress phase 0 selectively in abnormal/ischemic tissue, shorten repolarization)  Ic - Flecainide, propafenone, moricizine (markedly depress phase 0, minimal effect on repolarization) 

A commonly used classification system (the Atlanta classification) divides Acute Pancreatitis into two broad categories [ 5 ]: Mild (edematous and interstitial) acute pancreatitis Severe (usually synonymous with necrotizing) acute pancreatitis The criteria for severe AP included any of the following: A Ranson's score of 3 or more ( table 1 ) ( calculator 1 ) An APACHE II score of 8 or more within the first 48 hours ( calculator 2 ) Organ failure (respiratory, circulatory, renal, and/or gastrointestinal bleeding) Local complications (pancreatic necrosis, abscess, or pseudocyst). SUMMARY AND RECOMMENDATIONS (from UpToDate) Acute pancreatitis can be divided into two broad categories: Edematous or mild acute pancreatitis and necrotizing or severe acute pancreatitis. (See  'Introduction'  above.) Treatment varies depending on the severity of the condition. (See  "Predicting the severity of acute pancreatitis" .) Mild pancreatitis

    The World Health Organization Surgical Safety Checklist   establishes protocols designed to prevent the occasional, but recurring errors that have led to harm. The Safety Checklist applies from the time before induction of anesthesia, through just before skin incision and on to the time before the patient leaves the operating room.

    The following discussion and accompanying flow diagram attempt to identify the relevant factors that must be weighed when creating a patient-specific airway strategy. Neither discussion nor flow diagram is meant to be prescriptive. Many factors impact the decision, including patient cooperation, consent, and the clinician’s expertise.

Degrees Celsius (°C) and Fahrenheit (°F):

    Relevant anatomy for percutaneous catheterization of the femoral artery and vein. The right femoral artery and vein run underneath the inguinal ligament, which connects the anterior-superior iliac spine and the pubic tubercle. The arterial puncture should be made approximately 1.5 to 2 fingerbreadths (3 cm) below the inguinal ligament and directly over the femoral artery pulsation. The venous puncture should be made at the same level but approximately 1 fingerbreadth medial to the arterial position. X, Puncture site. (From Baim DS, Grossman W. Percutaneous approach. In: Grossman W, ed. Cardiac Catheterization and Angiography [3rd ed.]. Philadelphia: Lea & Febiger; 1986:60.)

    Wolff-Parkinson-White Syndrome ( WPW) is caused by the presence of an abnormal  accessory electrical conduction pathway ( the bundle of Kent )  between the  atria  and the  ventricles . It may stimulate the ventricles to contract prematurely.

  The tool developed to determine which patients might pose airway management difficulties is the LEMON method.

    Guidelines on checking anaesthetic equipment have been published by  the Association of Anaesthetists of Great Britain and Ireland (AAGBI),  and amongst others, the American Society of Anesthesiologists, the  Australian and New Zealand College of Anaesthetists and the World  Federation of Societies of Anesthesiologists. 

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Coma :   Closed eyes, sleeplike state  with no response to external stimuli (pain). People have no corneal or gag reflex, and they may have no pupillary response to light. Stupor : Responsive only to vigorous or painful stimuli by grimacing or drawing away from painful stimuli. Obtunded : A person has a decreased interest in their surroundings, slowed responses, and sleepiness.

    Increased hydrostatic pressure in the pulmonary capillaries results in increased transvascular fluid filtration and is most often caused by volume overload or impaired left ventricular function resulting in elevated pulmonary vascular pressures.

Cardiorespiratory arrest or impending arrest.

    In left bundle branch block there is a delay or blockage of conduction in the main left bundle  branch. This affects the normal depolarisation in the ventricles.     In left bundle branch block, the impulse begins in the SA node and depolarises the atria, then  travels through the AV node to the left and right bundle branches. On finding the left bundle branch  blocked, the impulse travels down the right bundle branch.

Hyperventilation – in the short term, hyperventilation to a PaCO2 of 25 mmHg can reduce cerebral blood flow, reducing ICP. This must be balanced, however, against the increased intrathoracic pressure required to hyperventilate the patient’s lungs, which can reduce venous return causing hypotension. Meanwhile vasoconstriction in the areas under carbon dioxide control might decrease compensatory blood flow. Mannitol – bolus administration of this 6-carbon sugar has three effects:

Face Mask LMA ETT Procedure duration Short Short–Medium Any Protection against aspiration No No Yes Peak inspiratory pressure* < 20 cmH2O < 20 cmH2O Any Stimulation by device Low Medium High LMA Laryngeal Mask Airway ETT Endotracheal Tube * Pressures above 20 cmH2O may distend the stomach

    SHOCK is a state of inadequate tissue perfusion, leading to tissue hypoxia and organ  dysfunction.      Shock is classified according to one of four mechanisms:

Drugs known to cause congenital malformations:

    Increased morbidity results from hypoxemia, hypoventilation resulting in acute hypercarbia, pulmonary infection, prolonged intubation, and mechanical ventilation. Patients presenting for lobectomy or pneumonectomy as well as those with pulmonary comorbidity must have pulmonary function and arterial blood gas values. A forced expiratory volume in 1 second (FEV1) less than 800 ml in a 70-kg person is probably incompatible with life and is an absolute contraindication to lung resection because of the high incidence for extended mechanical ventilation.

The anesthetic level required depends on the surgical procedure.  Dermatomal level requirements for a selection of  operations:

         Endotracheal tube sizing:

         ACC/AHA cardiac evaluation and care algorithm for non-cardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. A stepwise approach to the risk assessment of patients with pre-existing cardiac disease, scheduled for surgery. Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by non-cardiac surgery, or intensified care.  click the picture to enlarge:

STATEMENT ON SMOKING CESSATION  Committee of Origin: Task Force on Smoking Cessation (Approved by the ASA House of Delegates on October 22, 2008, and reaffirmed on October 16, 2013) 

    Postoperative nausea and vomiting ( PONV   ) is the result of multiple  of perioperative factors such as fasting, autonomic imbalance,  pain, and anesthetic effects on chemotactic centers.     The emetic centers are located in the lateral reticular formation of the medulla.

    The severity of a burn injury is based on the amount of surface area covered in deep  partial-thickness, full-thickness, and subdermal burns. The rule of nines method allows  reasonable estimation. Because of the difference in body habitus (particularly  head and neck), the rule of nines must be altered in children.

    The  King's College Criteria  or the  King's College Hospital criteria  were devised in 1989 to determine if there were any early indices of poor prognosis in patients with  acute liver failure (ALF) and to identify patients with ALF who would benefit from liver transplantation.

     Laryngospasm is a potentially life-threatening condition that can be managed through expeditious use of sedation, neuromuscular blockers, and airway maneuvers. Patients at high risk for this complication can be identified and measures taken to prepare for this complication.

          Morbidity and mortality associated with herbal use may be more likely in the perioperative period because of the polypharmacy and physiological alterations that occur.    Such complications include bleeding from garlic, ginkgo, and ginseng and potential interaction between ginseng-warfarin.  It is especially important for anesthesiologists to be familiar with related literature on herbal medications when caring for patients in the perioperative period.       Garlic Garlic is one of the most extensively researched medicinal plants. It has the potential to modify the risk of developing atherosclerosis by reducing blood pressure, thrombus formation, and serum lipid and cholesterol levels. The usual dosage is 4 g (∼2 cloves) of fresh bulb or its equivalent as an extract or tincture per day. Garlic inhibits in vivo platelet aggregation in a dose-dependent fashion. The effect of one of its constituents, ajoene, seems to be irreversible and may potentiate the effec

          Local anesthetic toxicity (LAST)  can occur because of inadvertent intravascular injection or dosing error. Intravascular injection can cause toxicity even if the anesthetic was administered within the recommended dose range.

         Arterial blood pH is normally 7.35–7.45.          Disorder that tends to reduce pH to a less than normal value is an acidosis , whereas one tending to increase pH is termed an alkalosis .     If the disorder primarily affects [HCO3 − ], it is termed metabolic . If the disorder primarily affects PaCO2 , it is termed respiratory .

    Patients with hypotension and shock without other cause are considered to have massive Pulmonary Embolism (PE) .     When obstruction occurs by embolism, the RV experiences an acute rise in pressure and volume, causing shift of the interventricular septum toward the left ventricle. In addition, as RV output  decreases,

    The Rapid Sequence Induction is a technique of inducing general anesthesia so as to reduce the risk of pulmonary aspiration of gastric contents.

          The general recommendation to use aspirin in children was withdrawn because of Reye syndrome, with use of aspirin only recommended in  Kawasaki disease .    Reye syndrome is a rapidly progressive encephalopathy.  

                       --  Back to reading recommendations  1 -16  -- Recommendation 17:  Oral administration of paracetamol is preferable to rectal administration in children, because absorption is more constant and it is possible to achieve a more precise dosage based on body weight (evidence level I; strength of recommendation A).