Transtracheal jet ventilation in a porcine model

Hypoxemia is a frequent event during difficult airway management. We propose to use transtracheal jet ventilation (TTJV) early during the management of complex difficult airway scenarios. The objective of this porcine study is to highlight the benefit of oxygenation via prophylactic TTJV. Eighteen pigs (Sus scrofa) were divided into two equal groups. In Group A, pigs were anesthetized and no lung ventilation was conducted following administration of succinylcholine and prior to tracheal intubation. Group B, after induction of anesthesia, received transtracheal ventilation using 100% oxygen. In both groups intubation was performed after waiting 90 seconds. All intubations were achieved in less than 30 seconds. Post-intubation arterial blood gases demonstrated significant hypoxemia in Group A (PaO2 22.6 + 5.8 mm Hg), while in Group B oxygenation substantially improved (PaO2 470.3 + 17.0 mm Hg). The arterial CO2 retention was associated with mild respiratory acidosis (pH 7.26 ± 0.05) in Group A only. These findings prove that prophylactic TTJV can improve oxygenation and allow extra time for definitive management of difficult airway

Emerging considerations in the reversal of neuromuscular blockade and residual block

Incomplete recovery following reversal of neuromuscular blockade can present as a clinical problem in surgical patients. Emerging pharmacologic solutions may prevent such adverse outcomes in the future. We briefly review two methods of pharmacologic reversal of neuromuscular blockade. Both methods of reversal are effective. However the early studies of the new compound, sugammadex has been shown to achieve a more rapid, stable reversal of steroidal based neuromuscular blocking agents compared to neostigmine. Due to the novel mechanism of action of this agent, sugammadex has been demonstrated to be effective even when administered during profound neuromuscular block, without evidence of recurarization

Perioperative Cardiac Arrests

Perioperative cardiac arrests represent the most serious complication of anesthesia and surgery. It is believed that the incidence and mortality of cardiac arrest has declined, however, a more recent review questioned whether these rates have changed over the last 5 decades. It is difficult to compare the reports from different epochs, because medical practice has advanced, surgical acuity increased, and patients in extremes of age undergo surgery today. In the present article we review the information regarding the incidence of perioperative cardiac arrests and predictors of survival covering the period since the first comprehensive report by Beecher and Todd in 1954. We focus on our publications that report perioperative cardiac arrest at Mayo Clinic for adult noncardiac surgery, during regional anesthesia, and arrests in our pediatric surgical practice

Delirium following total joint replacement surgery

Postoperative delirium (POD) is a common complication associated with increased resource utilization, morbidity and mortality. Our institution screens all postsurgical patients for postoperative delirium. The study aim was to perform an automated interrogation of the electronic health records to estimate the incidence of and identify associated risk factors for POD following total joint arthroplasty (TJA). Adult patients who underwent TJA with a multimodal analgesia protocol, including peripheral nerve blockade, from 2008 through 2012, underwent automated chart review. POD was identified by routine nursing assessment and administrative billing codes. Of 11,970 patients, 181 (1.5%) were identified to have POD. Older age (odds ratio, 95% CI 2.20, 1.80–2.71 per decade, p < 0.001), dementia (7.44, 3.54–14.60, p < 0.001), diabetes mellitus (1.70, 1.1.5–2.47, p = 0.009), renal disease (1.68, 1.03–2.65, p = 0.039), blood transfusions (2.04, 1.14–3.52, p = 0.017), and sedation during anesthesia recovery (1.76, 1.23–2.51, p = 0.002) were associated with POD. Anesthetic management was not associated with POD risk. Patients who developed POD required greater healthcare resources. Dementia is strongly associated with POD. The association between POD and transfusions may reflect higher acuity patients or detrimental effect of blood. Postoperative sedation should be recognized as a warning sign of increased risk

Acute phenibut withdrawal: A comprehensive literature review and illustrative case report

Phenibut is a glutamic acid derivative with activity on the γ-aminobutyric acid (GABA) B and A, and β-phenethylamine receptors. It is prescribed in former Communist Bloc countries for anxiolysis and related psychiatric disorders. It can be easily obtained in Western countries, and is thought to have abuse potential. Abrupt discontinuation has been reported to precipitate an abstinence syndrome. A review of the literature identified 22 reported cases, many of which were notable for severe psychomotor agitation and requirements for aggressive pharmacologic treatment. Neurologic and autonomic signs and symptoms may mimic serotonin or neuroleptic malignant syndrome. Patients were typically younger and had coexisting substance abuse disorders to other drugs. Also presented is a case of a 23-year-old male with an acute phenibut abstinence syndrome. This patient exhibited severe psychomotor agitation requiring physical restraints, dexmedetomidine, lorazepam, haloperidol, diphenhydramine, cyproheptadine, melatonin, olanzapine, and baclofen for symptom control

Pediatric surgical extracorporeal membrane oxygenation - a case series

Objective. To review demographic and procedural factors and their association with weaning rate and survival from extracorporeal membrane oxygenation (ECMO) in pediatric patients undergoing repair of cardiac malformations. Methods. The hospital records of children requiring ECMO during cardiac operation due to failure to wean from cardio-pulmonary by pass (CPB) were retrospectively reviewed, and an analysis of variables affecting survival was performed. Results. Thirty-five pediatric patients between January 1, 2000 and December 31, 2006 required ECMO for cardiopulmonary support during cardiac operations. ECMO survival was 54.3% and was comparable across all age groups. The lowest pH during ECMO treatment was the only predictor of mortality (P = 0.006). No other patient, surgical or anesthetic, factor was associated with either weaning from ECMO or hospital survival. Conclusions. No clear risk factor could be identified for survival from ECMO in our pediatric patients who underwent cardiac surgery and failed weaning from cardiopulmonary bypass

Survey of self-assessed preparedness for clinical practice in one Croatian medical school

<p>Abstract</p> <p>Background</p> <p>The Croatian higher education system is in the process of reforming its medical curricula to comply with European Union standards. We conducted a survey of students enrolled at the University of Zagreb (Croatia) asking them to rate their perception of preparedness for clinical practice prior to initiation of the reform process. The purpose of the survey was to identify self-perceived deficiencies in education and to establish a reference point for the later assessment of ongoing educational reform.</p> <p>Findings</p> <p>One-hundred and forty seven (N = 147) graduates reported the levels of perceived preparedness on 30 items grouped into 8 educational domains. Main domains were: understanding science, practical skills/patient management, holistic care, prevention, interpersonal skills, confidence/coping skills, collaboration, and self-directed learning. For each item, graduates self assessed their preparedness on a scale ranging from 1 to 4, with 1 = "Very inadequate", 2 = "Somewhat inadequate", 3 = "Somewhat adequate", and 4 = "Very adequate". In 7 out of 8 domains the achieved median score was ≥ 3. Students expressed low confidence (defined when ≥ 25% of respondents supplied a rating for the survey question as: "very inadequate" or "somewhat inadequate") with interpersonal skills (discussing terminal disease, counseling distraught patients, balancing professional and personal life), and in performing certain basic semi-invasive or invasive procedures.</p> <p>Conclusion</p> <p>Zagreb medical graduates identified several deficiencies within educational domains required for standard clinical practice. Ongoing educational efforts need to be directed towards the correction of these deficiencies in order to achieve standards required by the European Union.</p

Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases

BACKGROUND: The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. ----- METHODS: We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. ----- RESULTS: Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. ----- CONCLUSION: The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates

Survival of outborns with congenital diaphragmatic hernia: the role of protective ventilation, early presentation and transport distance: a retrospective cohort study

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a congenital malformation associated with life-threatening pulmonary dysfunction and high neonatal mortality. Outcomes are improved with protective ventilation, less severe pulmonary pathology, and the proximity of the treating center to the site of delivery. The major CDH treatment center in Croatia lacks a maternity ward, thus all CDH patients are transferred from local Zagreb hospitals or remote areas (outborns). In 2000 this center adopted protective ventilation for CDH management. In the present study we assess the roles of protective ventilation, transport distance, and severity of pulmonary pathology on survival of neonates with CDH. ----- METHODS: The study was divided into Epoch I, (1990-1999, traditional ventilation to achieve normocapnia), and Epoch II, (2000-2014, protective ventilation with permissive hypercapnia). Patients were categorized by transfer distance (local hospital or remote locations) and by acuity of respiratory distress after delivery (early presentation-occurring at birth, or late presentation, ≥ 6 h after delivery). Survival between epochs, types of transfers, and acuity of presentation were assessed. An additional analysis was assessed for the potential association between survival and end-capillary blood CO2 (PcCO2), an indirect measure of pulmonary pathology. ----- RESULTS: There were 83 neonates, 26 in Epoch I, and 57 in Epoch II. In Epoch I 11 patients (42%) survived, and in Epoch II 38 (67%) (P = 0.039). Survival with early presentation (N = 63) was 48 % and with late presentation 95% (P <0.001). Among early presentation, survival was higher in Epoch II vs. Epoch I (57% vs. 26%, P = 0.031). From multiple logistic regression analysis restricted to neonates with early presentation and adjusting for severity of disease, survival was improved in Epoch II (OR 4.8, 95%CI 1.3-18.0, P = 0.019). Survival was unrelated to distance of transfer but improved with lower partial pressure of PcCO2 on admission (OR 1.16, 95%CI 1.01-1.33 per 5 mmHg decrease, P = 0.031). ----- CONCLUSIONS: The introduction of protective ventilation was associated with improved survival in neonates with early presentation. Survival did not differ between local and remote transfers, but primarily depended on severity of pulmonary pathology as inferred from admission capillary PcCO2

Anesthesia and Patients with Congenital Hyposensitivity to Pain

Background: Congenital hyposensitivity to pain or hereditary sensory and autonomic neuropathy represents a variety of disorders characterized by decreased perception of nociception, loss of other modalities of sensation, and variable expression of autonomic dysfunction. Sensory loss, especially that of pain, is associated with self-mutilations that may require frequent operations. Little is known about the safety of anesthesia for these patients. Methods: The authors performed a computerized search of the Mayo Clinic medical records database between January 1996 and November 2005 for patients with congenital hyposensitivity to pain and related disorders who underwent general anesthesia. Medical records were reviewed for demographics, anesthetic techniques and agents, use of opioids, and perioperative complications. In addition, the authors conducted a comprehensive review of the literature to summarize the current knowledge regarding anesthesia for patients with congenital hyposensitivity to pain, and compared it with the patients with hyposensitivity to pain identified at the Mayo Clinic. Results: The authors identified seven patients with hereditary sensory and autonomic neuropathy II, IV, or V and undefined variants of congenital pain hyposensitivity who generated 17 anesthesia records: 12 for orthopedic operations, 3 for sural nerve biopsies, and 2 for ophthalmologic procedures. In all patients, standard doses of volatile agents were used during anesthesia. Small amounts of opioids were used during the course of eight operations. Most patients experienced mild hypothermia (lowest temperature 34.7°C), and none experienced hyperthermia. All patients were hemodynamically stable during otherwise uneventful anesthesia. During recovery from anesthesia, opioids were given to only one patient, a single dose of 1 mg morphine. Even after major orthopedic operations, the patient did not require additional analgesia. Conclusions: The patients with profound congenital hyposensitivity to pain underwent anesthesia without any adverse events. The authors found that despite reduced pain perception, the requirements for volatile anesthetics were within the expected range for population with normal pain perception, but they did not require opioids postoperatively. Intraoperative mild hypothermia was easily managed by adjustment of environmental temperature