Intraoperative Valsalva maneuver: a narrative review

The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic\ua0pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented

Anesthetic management of the illicit-substance-using patient

During the last few years, drug abuse has risen to the point that almost 20 million Americans are current abusers of illicit substances. These patients present to us as anesthesiologists in a variety of circumstances: in obstetrics for labor and emergencies, in trauma for emergency surgeries or life-saving (resuscitative) situations and in everyday elective surgeries. Therefore it is important for anesthesiologists to know about the most common illicit drugs being used, to know their side effects and clinical presentation if abused or intoxicated, and to know what anesthetic options would be beneficial or detrimental. In this article we will review some of the most commonly used illicit drugs, their effects on the organ systems and some tips to take into consideration when providing anesthesia for these patients. We will discuss marijuana, cocaine, opioids, hallucinogens, solvents and the newer so-called rave or club drugs. Newer treatment options for opioid detoxification will also be discussed. Illicit substance abuse is a major health concern in the United States. Drug use, either acute or chronic, has potentially grave consequences which include changes affecting the pulmonary, cardiovascular, nervous, renal and hepatic systems. Anesthesiologists come into contact with these patients in emergency and everyday situations. Due to the diverse clinical presentations that may arise from single substance or polysubstance abuse, anesthetic management should be tailored to each individual and universal precautions should always be followed when providing care

Intraoperative cell salvage: a technology built upon the failures, fads and fashions of blood transfusion

Transfusion, as we know it today, developed into a very sophisticated treatment modality as a result of centuries of experimentation. Intraoperative cell salvage is a transfusion technique where autologous blood lost during surgery is reinfused. The success of this process relies on specialised equipment and techniques to collect, process, anticoagulate filter and reinfuse blood. Through a literature review, we collected information about the early origins of specific techniques relevant to intraoperative cell salvage: the ability to collect lost blood, to prevent collected blood from clotting, to remove debris through processing and other harmful aspects through filtering, the benefits of autologous blood transfusion, reinfusion and traditional concerns and contraindications. A culmination of knowledge specific to each of these techniques over centuries provides the background to the safe intraoperative cell salvage technique used today. In addition, we aimed to identify the reasons why specific equipment and techniques developed, why practice changed and what is still unknown. This article reviews relevant allogeneic transfusion and autotransfusion history, starting in Roman times, and includes landmark events through the centuries

Operating room greening initiatives – the old, the new, and the way forward: a narrative review

Healthcare waste is a rampant issue in Australian hospitals. The operating room (OR) contributes disproportionately to total hospital waste. There has been considerable research in the literature concentrating on strategies to improve OR and hospital waste accumulation, in an attempt to provide guidance and direction on how to reduce the healthcare ecological footprint. We reviewed the literature for leading greening initiatives currently utilised in the OR in Australia and internationally. This narrative literature review focuses on the trend of OR greening initiatives over the last 25 years, comparing different innovative approaches, the successes and setbacks, and the financial implications of initiatives. A variety of measures that hospital management, surgeons, anaesthetists, nurses and other healthcare personnel can take to reduce the ecological footprint of their healthcare facility are outlined. Greening initiatives include reducing, recycling, reusing, rethinking and researching, as well as novel technology and smarter architectural design. We also evaluated the barriers to improving waste management, which include lack of leadership, misconceptions among staff, and an overall resistance to change. In conclusion, in a world where greenhouse gas emissions cause unprecedented climate change and landfill space is finite, it is incumbent upon hospitals to help reduce the environmental impact of their facility. Reducing pollution and greenhouse gas emissions would moderate the incidence of human disease, save money for the healthcare system and society as a whole, and contribute to a safer and healthier world we all would like to live in

Comparison of the diameter, cross-sectional area, and position of the left and right internal jugular vein and carotid artery in adults using ultrasound

Study objective: Central venous access is indicated for transduction of central venous pressure and the administration of inotropes in the perioperative period. The right internal jugular vein (RIJV) is cannulated preferentially over the left internal jugular vein (LIJV). Cannulation of the LIJV is associated with a higher complication rate and a perceived increased level of difficulty when compared with cannulation of the RIJV. Possible explanations for the higher complication rate include a smaller diameter and more anterior position relative to the corresponding carotid artery (CA) of the LIJV compared with the RIJV. In this study, the RIJV and LIJV were examined in mechanically ventilated patients to determine the validity of these possible explanations. Design: A prospective, nonrandomized cohort study. Setting: The operating room of a major teaching hospital. Patients: One hundred fifty-one patients scheduled for elective heart surgery. Intervention: Ultrasound examination of the RIJV and LIJV at the level of the cricoid cartilage with a 12-MHz linear transducer in 151 anesthetized, mechanically ventilated patients in the Trendelenburg position. Measurements and results: In 72% of patients, the RIJV was dominant over the LIJV. The diameter and cross-sectional area of the RIJV was larger than the LIJV (

A prospective randomized comparison of airway seal using the novel vision-guided insertion of LMA-Supreme® and LMA-Protector®

The laryngeal mask airways supreme (LMA-Supreme™) and protector (LMA-Protector™) are generally placed blindly, often resulting in a less than optimal position and vision-guided placement has been recommended. This prospective, randomized controlled study compared the efficacy of airway seal by measuring the oropharyngeal leak pressure in 100 surgical patients who underwent a variety of non-thoracic surgery under general anaesthesia, suitable with a supraglottic airway device. Patients were allocated to either the LMA-Supreme (n = 50) or LMA-Protector (n = 50) group. All insertions were performed under vision of a videolaryngoscope using an ‘insert-detect-correct-as-you-go’ technique with standardized corrective measures. Our primary endpoint, mean oropharyngeal leak pressure, was significantly higher in the LMA-Protector (31.7 ± 2.9\ua0cm H O) compared to the LMA-Supreme (27.7 ± 3.5 cm H O) group (mean difference 4.0 cm H O, 95% confidence interval (CI) 2.7–5.3 cm H O, p < 0.001) after achieving a near-optimal fibreoptic position in the LMA-Protector (94%) and LMA-Supreme (96%) groups. No statistically significant differences were shown for secondary outcomes of alignment, number of insertion attempts and malpositions, and final anatomical position as scored by fibreoptic evaluation. Corrective manoeuvres were required in virtually all patients to obtain a correct anatomically positioned LMA. Position outcomes of the two devices were similar except for the proportion of procedures with folds in the proximal cuff (90% LMA-Supreme vs. 2% LMA-Protector, p < 0.001), the need for intracuff pressure adjustments (80% LMA-Supreme vs. 48% LMA-Protector, p = 0.001) and size correction (18% LMA-Supreme vs. 4% LMA-Protector, p = 0.025). In conclusion, a higher oropharyngeal leak pressure can be achieved with LMA-Protector compared to LMA-Supreme with optimal anatomical position when insertion is vision-guided