1,721,006 research outputs found
Unintetional tracheal extubation during prone position: what is the best rescue airway device?
Full text linkUnintentional tracheal extubation during surgery is a dramatic situation and may be a life-threatening event if it is not followed by a rapid reintubation. This is particularly true in patients with difficult airways or in patients whose airways are difficult to access such as patients undergoing facial surgery or in prone position. The patient prone is a problem for the anesthesiologist because accidental tracheal extubation in this setting could be a catastrophic event often treated by turning the patient supine for ventilation and tracheal re intubation. However, patient's rotation in supine position is not always achievable and requires time, the support of personnel not necessarily immediately available, and it may contaminate the sterile surgical field with serious postoperative complications.[1] In the last years, several reports have been published to describe the anesthesiological management after unexpected intraoperative tracheal extubation particularly focusing on devices more often used.[2,3] The laryngeal mask airway (LMA) has become the most used device in the catastrophic situation “cannot intubate, cannot ventilate” and in literature, it has been described its insertion as rescue airway management in patients with unintentional tracheal extubation during general anesthesia in prone position.[4] In 1993, McCaughey and Bhanumurthy have inserted for the 1st time a supraglottic airway device (SAD) following the induction in prone position and from that time several studies have been performed to valuate the facility and the security of insertion in this position. In fact, it has been shown that prone insertion may be easy as in the supine because the tongue falls anteriorly and creates an open space for the placement of LMA device (LMAD), whose seal is improved by the cephalic displacement of the larynx. Moreover, the risk of aspiration is reduced because regurgitant fluid for the gravity will be drained from the airway.[5] In the issue of “Journal of Emergencies, Trauma, and Shock” Gupta et al. describe an observational study that they conducted to test the feasibility of SAD insertion for ensure airway ventilation in prone position and fixed head as in neurosurgical patients during accidental extubation.[6] Forty partecipanting anesthesia residents were asked to place to airway trainer (Laerdal) manikin in the prone position three SADs; i-gel, LMA ProsealTM (PLMA), and LMA ClassicTM (CLMA). The authors found that despite all three SADs were successful as rescue devices during accidental extubation in prone position, however, the ease of insertion was maximum with i-gel followed by CLMA and PLMA, in fact, i-gel was characterized by fewer time taken for insertion, least resistance in insertion, no maneuvers required for optimal positioning and bronchoscopic view and insertion score was significantly higher with i-gel as compared to CLMA and PLMA. Therefore, the authors compared three different SADs of which CLMA belongs to the first generation of LMA, whereas PLMA and i-gel to second generation of LMA. Second generation LMA was born to reduce the problems associated to the first generation LMA such as the difficult in positioning, the relatively low airway pressures with the risk of aspiration, and dislodgment. The second generation LMADs like proseal have a gastric channel allowing the passage of a tube for gastric decompression. i-gel is a more recent SAD with a non-inflatable cuff made of a thermoplastic elastomer, able to provide a seal by conforming to differently shaped throats. Several studies have compared the i-gel with various types of LMADs regarding to efficacy and ease of insertion. In a systematic review and meta-analysis performed by de Montblanc et al., i-gel was superior regarding first generation LMAD in terms of time of insertion and leak pressure despite this superiority was not for i-gel compared to the second generation LMADs. The main clinical advantage of the i-gel was the less frequent sore throat.[7] Furthermore, in the study of Gupta et al. i-gel seems to have better quality of insertion. The novelty of this manuscript is that the authors' aim was to compare the insertion of different SADs in prone position during emergency situations such as accidental extubation and nowadays the evidence is lacking regarding the feasibility of SADs insertion in prone position in emergency situations because all the data were derived from elective setting or observational studies and case reports and translation of experience of elective cases into emergent situations could be misleading. It is not ethic to conduct randomized clinical trials to test the best rescue airway device for emergency airway management. Therefore, the authors have tried to get around this limit by performing a manikins study. In recent years, it became very difficult to conduct clinical research and obtain ethical approval. Therefore, it was born a research based on manikin studies. For these studies, the approval ethic committee is usually easily obtained, there are no adverse effects, and the studies can be fastly completed. However, manikins are not like real patients for their hard plastic and lack of secretions so the results cannot be simply extrapolated and extended to humans. Howes et al. have evaluated the insertion of LMA supreme first in a manikin and then in patients. All partecipants have inserted successfully the device at the first attempt in the manikin phase of the study. In the patient phase of the study, insertion was successful in only 86% of cases on the first attempt.[8] Rai and Popat have attributed this difference to population diversity that could not be simulated and that is clinically challenging.[9] The studies evaluating the feasibility of insertion of SADs in elective prone position after induction of anesthesia have stressed that the anesthesiologist should have considerable experience with the use of supraglottic airways in the prone position and that for these techniques low-risk patients should be selected. Moreover, the frequent endpoints of the studies regarding positioning of SADs in prone position evaluate the simplicity of insertion, the reduction of complications, and the insertion speed but probably the most important issue in this situation is the most appropriate SAD in terms of successful of insertion, adequate ventilation, utility for intubation through laryngeal mask, and the best position of the operator to insert the device. In fact, for the insertion in prone position different techniques have been described. Some authors describe the insertion of the SAD by the anesthesiologist while an assistant opens the patient's mouth by extending the tip of the patient's chin while in the Stevens and Mehta technique the assistant extends and turns the patient's head to the side.[10,11] However, the condition of insertion of SAD is quite different in an emergency situation, and the expertise of the operator is very important to position the LMA. The insertion of SAD is not elective, and the head cannot be turned. The evenience of an unaspected extubation during surgery in the operating room is not paragonable with the scenario described by authors. Therefore, it is not possible to extrapolate the experiences from the elective to the emergent situation since the insertion of SADs in prone position and emergency situations is not like the insertion in elective series where preoxygenation is often performed and a second bed is positioned alongside the operating table. Furthermore, the assistance of another operating room nurse or anesthesia assistant is often required to open the patient's mouth during the SAD insertion.[10] In conclusion, more prospective randomized studies are needed to investigate the best management for airway management in patient in prone position. Many questions exist regarding to the best device to be used for the feasibility of insertion and the patient's security and currently, the first recommendation for the anesthesiologists involved in surgical procedures with the patient in prone position is to firmly anchor the endotracheal tube to avoid an accidental extubation because the question regarding which SAD is the best choice is still unresolved
The use of NSAID,s in the postoperative period:advantage and sdisfantages.
No full textNSAIDs are commonly used as single analgesics in minor surgery or as component of multimodal analgesia with opioids or locoregional techniques in the postoperative period to assure a better analgesia and reduce the dose of opioids. The analgesic potency evaluated as number needed to treat (NNT) is not very different between the traditional non selective NSAIDs and the selective cyclo-oxygenase-2-inhibitors (Coxibs). The effectiveness as analgesic is unquestionable also if these drugs are not devoid to risk. There is debate in literature about the possible side effects when administrered in the perioperative period: anastomotic leakage, reduced ossification, bleeding and acute renal failure. Recent data underline ad the Coxibs but also traditional NSAIDs can induce cardiac toxicity even if they are utilizrd for few days. The aim of this review is to provide an overview of the effectiveness and side effects of selectie and nonselective NSAIDs in the perioperative perio
Resumption of sinus rhythm during general anaesthresia in an elderly patient with chronic atrial fibrillation: a case report
No full textConversion to sinus rhythm is a rare event in a patient with chronic atrial fibrillation. There are no reports in the literature of this happening during general anaesthesia. This case report presents such a case and discusses the possible aetiology
Postoperative Cognitive Dusfunction in Elderly Patients:A frequent Complication
No full textPrevention of postoperative cognitive dysfunction (POCD) is still a challenge for the anesthesiologist. Systemic responses induced by surgery might trigger neuroinflammation and POCD
new drugs for epidural analgesia
No full textIn recent years there has been a wide use of the epidural technique not only during surgery to provide anesthesia and analgesia, but also for obstetric and trauma as well as acute, chronic and cancer pain states. Nowadays there is an increase in the number of the epidural drugs. Local anesthetics and opioids are still the pharmacological agents more widely used epidurally, nevertheless other drugs from different pharmacological classes are administered as adjuvant to local anesthetics and opioids or are in various early stages of investigation. Regarding to local anesthetics, the most recent literature focuses on the new enantiomers, ropivacaine and levobupivacaine, the efficacy of which is similar to that of bupivacaine with a reduced risk of cardiotoxicity. About opioids, the other class of drugs mainly used, the debate, in the last years, concerned the physicochemical properties of morphine and of the more recent lipophilic agents, fentanyl and sufentanil, in order to explain the main differences in efficacy and safety. Other categories of agents have been investigated for epidural administration, such as alpha(2)-adrenergic agonists clonidine and dexmedetomidine. They are being used increasingly as adjuvants to local anesthetics and opioids. Ketamine and neostigmine, the more recent studied drugs for epidural use, are still under investigation and are not part of routine clinical practice
Postoperative analgesia in thoracic surgery: a comparison between continuous paravertebral nerve block and continuous incisional infusion with OnQ pain relief system
No full textThoracotomy is one of the most painful surgery and inadequate management of post-thoracotomy pain is often associated with pulmonary and cardiac complications. The aim of this prospective, randomized, double-blinded study was to compare continuous paravertebral block versus continuous incisionale infusion with OnQ Pain Relief Syste
A year in review in Minerva Anestesiologica, 2010
No full textIn this review are reported the mosto important articles published in Minerva Anesthesiologica during the 2010. The article reports the main advances in anesthesia, analgesia and pain therap
A year in Minerva Anestesiologica 2014
No full textThis is a review of the most important articles of Minerva Anestesiologica of 201
Changes of hemodynamics during isoflurane and propofol anesthesia: a comparison study
No full textOBJECTIVES:
Volatile anesthetics are thought to impair cerebral autoregulation more than i.v. anesthetics. However, few comparative studies have been carried out in humans. The aim of our study was to evaluate the differences in cerebral hemodynamic changes after introduction of isoflurane (a volatile anesthetic) and propofol (an i.v. anesthetic).
METHODS:
Eighteen consecutive patients submitted to laparoscopic cholecystectomy were selected. After the induction, anesthesia was maintained by isoflurane (one minimum alveolar anesthetic concentration) during the first part of the surgical operation, and then by propofol (5 mg/kg/hour i.v.). Ventilation was adjusted to maintain a constant end-tidal CO(2). Middle artery flow velocity was assessed by means of transcranial Doppler ultrasonography. Arterial blood pressure, heart rate (HR), capnometry, pulse oxymetry, inspired fraction of O(2), and body temperature, were monitored.
RESULTS:
Cerebral artery velocity, HR, and mean arterial pressure all significantly increased from baseline after the introduction of isoflurane (p<0.05); the HR and mean arterial blood pressure showed no significant difference between the isoflurane and propofol phases. Isoflurane anesthesia induced a significant increase in cerebral blood velocity. Propofol introduction led to a significant decrease in cerebral artery velocity (p<0.05).
CONCLUSIONS:
Propofol but not isoflurane decreased cerebral blood velocity thus restoring cerebral autoregulation and the coupling between cerebral blood flow and cerebral metabolism
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