Anesthesiology and Intensive Care

    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.

Local Anesthetic Toxicity, Treatment Checklist keywords: Local anesthetic systemic toxicity, LAST treatment, Local anesthetic toxicity, Lipid emulsion therapy, Anesthesia complications, Treatment of LAST, Bupivacaine toxicity           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.

        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:

Propofol-related Infusion Syndrome is an acute refractory bradycardia leading to asystole and one or more of: Metabolic acidosis (base deficit > 10 mmol.l(-1)) Rhabdomyolysis Hyperlipidaemia Enlarged or fatty liver Risk Factors: Assosiated with propofol infusions at doses higher than 4 mg/kg/h  for greater than 48 h duration. Young age Low carbohydrate intake Corticosteroids intake Catecholamine infusion Pathogenesis:      Unclear, but may be associated with    impaired mitochondrial fatty acid metabolism,  mediated by propofol.   Clinical signs: Hemodynamic instability Requirement of  inotrope support Green urine ECG: right bundle branch block with convex-curved ('coved type') ST elevation in the right praecordial leads (V1 to V3). Blood gases: lactic acidosis;  Electrolytes: hyperkalaemia (in case of rhabdomyolysis, acute kidney failure) Lipaemic serum Treatment: ...

Common Signs and Symptoms: ECG Signs: Bigeminy: Regularised AF: Bidirectional VT: Atrial flutter with AV block: MANAGEMENT: Stop Digoxin Correct Hypokalemia Use caution if Heart Block is present Treat arrhythmias : Bradyarrhythmias digibind atropine adrenaline (but may aggravate cardiac irritability) pacing (rarely effective) Tachyarrhythmias digibind MgSO 4  as an adjunctive measure Lignocaine (unproven) often refractory to cardioversion Avoid potentially harmful interventions Calcium infusion (e.g. Calcium Chloride or Calcium Gluconate) "Stone heart" theoretical concern that intracellular calcium is already high in Digoxin Toxicity However original theory was from the 1950s and recent studies fail to find significant effect ( Levine (2011) J Emerg Med 40(1):41-6 +PMID:19201134 [PubMed] ) Catecholamines Electrical Cardioversion Safe if...

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VOLATILE ANESTHETIC TOXICITIES • Carbon monoxide can accumulate due to desflurane degradation by dry CO 2 absorbent, especially barium hydroxide . Th is can also occur with sevoflurane and isoflurane . Avoid this by discarding desiccated CO 2 absorbent. • High-output renal failure can result from fluoride levels greater than 50 micromoles per liter produced by methoxyflurane metabolism. • Compound A accumulation results from sevoflurane degradation with soda lime or barium hydroxide lime. Ensure fresh gas fl ows greater than 2 L/min to avoid rebreathing of Compound A. • Macrocytic anemia can be caused by nitrous oxide exposure because it irreversibly oxidizes the cobalt atom in vitamin B12 and thus inhibits all vitamin B12-dependent enzymes. Nitrous oxide increases the risk of bone marrow suppression, macrocytic anemia, and peripheral neuropathies . • Fulminant hepatic necrosis and less severe hepatic dysfunction have been associated with halothane expos...