Tracheal intubation in the prone position with an intubating laryngeal mask airway following posterior spine impaled knife injury

A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation

Comparison of two ventilation modes in post-cardiac surgical patients

Background: The cardiopulmonary bypass (CPB)-associated atelectasis accounted for most of the marked post-CPB increase in shunt and hypoxemia. We hypothesized that pressure-regulated volume-control (PRVC) modes having a distinct theoretical advantage over pressure-controlled ventilation (PCV) by providing the target tidal volume at the minimum available pressure may prove advantageous while ventilating these atelactic lungs. Methods: In this prospective study, 36 post-cardiac surgical patients with a PaO 2 /FiO 2 (arterial oxygen tension/Fractional inspired oxygen) < 300 after arrival to intensive care unit (ICU), (n = 34) were randomized to receive either PRVC or PCV. Air way pressure (Paw ) and arterial blood gases (ABG) were measured at four time points [T1: After induction of anesthesia, T2: after CPB (in the ICU), T3: 1 h after intervention mode, T4: 1 h after T3]. Oxygenation index (OI) = [PaO 2 / {FiO 2 × mean airway pressure (Pmean )}] was calculated for each set of data and used as an indirect estimation for intrapulmonary shunt. Results: There is a steady and significant improvement in OI in both the groups at first hour [PCV, 27.5(3.6) to 43.0(7.5); PRVC, 26.7(2.8) to 47.6(8.2) (P = 0.001)] and second hour [PCV, 53.8(6.4); PRVC, 65.8(7.4) (P = 0.001)] of ventilation. However, the improvement in OI was more marked in PRVC at second hour of ventilation owing to significant low mean air way pressure compared to the PCV group [PCV, 8.6(0.8); PRVC, 7.7(0.5), P = 0.001]. Conclusions: PRVC may be useful in a certain group of patients to reduce intrapulmonary shunt and improve oxygenation after cardiopulmonary bypass-induced perfusion mismatch

Blood transfusion practices in cardiac anaesthesia

The primary reasons for blood transfusion in cardiac surgery are to correct anaemia and to improve tissue oxygen delivery. However, there is a considerable debate regarding the actual transfusion trigger at which the benefits of transfusion overweight the risk. The association between extreme haemodilution, transfusion and adverse outcome after cardio pulmonary bypass (CPB) is not clear and the current available literature is not sufficient to provide a strong recommendation regarding the safe haematocrit range during CPB. There is no quality evidence to support use of fresh red blood cell except during massive transfusion or exchange transfusion in neonate. Overall concern regarding the safety of allogeneic blood transfusion resulted in the search for autologous blood transfusion and perioperative blood salvage. The aim of this review is to provide cardiac surgery specific clinically useful guidelines pertaining to transfusion triggers, optimal haemodilution during CPB, autologous blood transfusion and role of perioperative blood salvage based on available evidence

The effect on post-operative pain of intravenous clonidine given before induction of anaesthesia

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications. Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery. Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial. Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0-100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption. Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fisher′s exact test. Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P<0.05). The sedation score was increased in the clonidine group during study drug infusion, but did not differ significantly on admission to the PACU. Conclusions: A single intravenous dose of clonidine (3 mcg/kg) given before induction of anaesthesia significantly reduced the post-operative VAS score in the initial period and fentanyl consumption during 24 h after thoracic surgery