1/18. Intubating laryngeal mask and rapid sequence induction in patients with cervical spine injury.The Intubating Laryngeal Mask (FastrachTM), a modified conventional laryngeal mask airway, and its prototype cuffed silicone tube, continue to be an appropriate intubating tool in combination with fibreoptic bronchoscopy in the emergency situation. This is an account of two patients with suspected cervical spine fracture admitted to our emergency room in a haemodynamically unstable condition and requiring a rapid sequence induction of anaesthesia, in whom we successfully applied this newly developed intubating device for the first time. Provided that there are no intubation difficulties, direct laryngoscopy is still the fastest method of securing an airway; however, this procedure leads to an extension of the cervical spine, which may be hazardous in the case of a cervical spine injury. intubation by means of the Intubating Laryngeal Mask avoids dangerous hyperextension of the occipito-atlanto-axial complex, a fact that we were able to verify by lateral cervical spine fluoroscopy during intubation.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
2/18. Remifentanil in emergency caesarean section in pre-eclampsia complicated by thrombocytopenia and abnormal liver function.We describe the use of remifentanil in a woman with severe pre-eclampsia who presented for emergency caesarean section. Remifentanil was effective in obtunding the hypertensive response to laryngoscopy and intubation. Previous studies have found no significant adverse effects of remifentanil on the neonate. With its short duration of action, the use of this new opioid has several potential advantages in the above setting. Further studies are required to explore the use of remifentanil as an adjunct to obstetric general anaesthesia.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
3/18. Unnecessary emergency caesarean section due to silent CTG during anaesthesia?We present a case of a probably unnecessary Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia. A 27-yr-old patient in her 30th week of an uneventful, normal first pregnancy presented with a deep venous thrombosis in the pelvic region. She was to undergo an emergency thrombectomy under general anaesthesia. During the operation, the CTG showed a lack of beat-to-beat heart rate variation (silent pattern CTG) with normal fetal heart rate. This silent CTG pattern was probably a result of the effect of general anaesthesia on the fetus. The CTG pattern was interpreted as indicating fetal distress, and an emergency Caesarean section was performed after the thrombectomy. The infant was apnoeic and had to be resuscitated and admitted to the neonatal intensive care unit. The pH at delivery was 7.23 and the baby was extubated 2 days later. Mother and child recovered without short-term sequelae. In the absence of alternative explanations, reduced fetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.- - - - - - - - - - ranking = 8keywords = anaesthesia (Clic here for more details about this article) |
4/18. Perioperative management of a cadasil type arteriopathy patient.We report the anaesthetic management of a patient suffering from an ischaemic arteriopathy of the cadasil (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy) type. The anaesthetic implications of this pathology are discussed. By analogy with other cerebral arteriopathies, the aim of our management was to keep mean arterial blood pressure and end-tidal carbon dioxide so as to prevent any cerebral ischaemic or vasospastic phenomenon. We preserved the cerebral venous return by avoiding excessive head-down position. We used a balanced anaesthetic technique because it allows easier titration of the depth of anaesthesia with regard to mean arterial pressure. There is no contraindication to the use of loco-regional anaesthesia.- - - - - - - - - - ranking = 2keywords = anaesthesia (Clic here for more details about this article) |
5/18. Local anaesthesia and sedation for rigid bronchoscopy for emergency relief of central airway obstruction.We report three experiences that illustrate the use of local anaesthesia for rigid bronchoscopy. All patients were acute emergencies, with life-threatening central airway problems. Instruments were inserted after the airway was anaesthetised using a technique that owes much to mid 20th Century methods for inserting endobronchial blockers. There is discussion about requirement to preserve and conserve self-ventilation and the securing of compromised central airways without the aid of neuromuscular blocking agents. Historical aspects of bronchoscopy are reviewed. Concomitant sedation reduced the unpleasantness of the experience in a way that in the past could only be dealt with by careful attention to the humanitarian elements of detail. Problems of oxygenation were ameliorated by periodically superimposing intermittent jetting with a Sanders injector fed from the oxygen pipeline. A need for developing and refining topical and other local anaesthetic techniques for rigid bronchoscopy is anticipated with the expansion of services for tracheo-bronchial stenting and lasering.- - - - - - - - - - ranking = 5keywords = anaesthesia (Clic here for more details about this article) |
6/18. Emergency tracheal catheterization for jet ventilation: a role for the ENT surgeon?Stridor causing respiratory failure is an ENT and anaesthetic emergency requiring prompt management to secure a clear airway. We describe a case of subacute partial upper airway obstruction due to a large laryngeal carcinoma in an 81-year-old male resulting in respiratory failure. The patient became apnoeic after gaseous induction of general anaesthesia, and after two failed intubation attempts an emergency transtracheal airway catheter was placed by the surgeon under direct vision below the cricothyroid membrane, as this had tumour involvement. The patient was subsequently manually jet-ventilated with ease until a formal tracheostomy was made. Where difficulties with tracheal anatomy are encountered due to the presence of pathology, the insertion of a temporary airway catheter for jet ventilation by the surgeon can buy valuable time and be life-saving.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
7/18. Emergency anaesthesia in a patient with Gordon's syndrome.Gordon's syndrome is a rare condition characterized by hypertension and hyperkalemia despite normal renal glomerular function. We report the administration of an anaesthetic to one such patient for an urgent surgical procedure. The patient's serum potassium was only marginally raised at the outset of the procedure. During surgery the serum potassium rose significantly, but responded to conventional management. Hyperkalaemia is a specific electrolyte disturbance that has numerous implications for the administration of an anaesthetic. Most importantly, there is a danger that further acute elevations may occur, caused by the surgery, the anaesthetic, or the condition itself- - - - - - - - - - ranking = 4keywords = anaesthesia (Clic here for more details about this article) |
8/18. Modelling emergency decisions: recognition-primed decision making. The literature in relation to an ophthalmic critical incident.AIMS: To review and reflect on the literature on recognition-primed decision (RPD) making and influences on emergency decisions with particular reference to an ophthalmic critical incident involving the sub-arachnoid spread of local anaesthesia following the peribulbar injection. BACKGROUND: This paper critics the literature on recognition-primed decision making, with particular reference to emergency situations. It illustrates the findings by focussing on an ophthalmic critical incident. DESIGN: Systematic literature review with critical incident reflection. methods: medline, CINAHL and PsychINFO databases were searched for papers on recognition-primed decision making (1996-2004) followed by the 'snowball method'. Studies were selected in accordance with preset criteria. RESULTS: A total of 12 papers were included identifying the recognition-primed decision making as a good theoretical description of acute emergency decisions. In addition, cognitive resources, situational awareness, stress, team support and task complexity were identified as influences on the decision process. CONCLUSIONS: Recognition-primed decision-making theory describes the decision processes of experts in time-bound emergency situations and is the foundation for a model of emergency decision making (Fig. 2). RELEVANCE TO CLINICAL PRACTICE: decision theory and models, in this case related to emergency situations, inform practice and enhance clinical effectiveness. The critical incident described highlights the need for nurses to have a comprehensive and in-depth understanding of anaesthetic techniques as well as an ability to manage and resuscitate patients autonomously. In addition, it illustrates how the critical incidents should influence the audit cycle with improvements in patient safety.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
9/18. Acute aortic occlusion presenting with lower limb paralysis.In a two year period eight patients have presented with acute aortic occlusion and a poor outcome in seven. Initial failure to diagnose aortic occlusion, with a mean delay from presentation to diagnosis of 24 hours, was mainly responsible. All patients had varying degrees of paralysis on presentation which misled clinicians although other findings of acute ischaemia (pain, absent pulses, colour change and anaesthesia) were always present. Two patients were initially referred to a neurologist, another to a neurosurgeon, and the fourth to an orthopaedic surgeon. Even after diagnosis had been established, the need for urgent revascularization was not always recognized, the mean time from diagnosis to revascularization being 13 hours. Unnecessary aortography contributed to this delay in four patients. In two patients operative treatment was not undertaken while six were treated operatively by: aortic bifurcation graft (3), aortic thromboendarterectomy and femoropopliteal bypass (1), open aortic embolectomy (1) and bilateral femoral embolectomy (1). The causes of aortic occlusion were thrombosis of an atherosclerotic aorta (5), thrombosis of an aneurysm (2) and embolism (1). In the latter patient, the heparin induced thrombocytopenia syndrome (HITS) was primarily responsible. The outcomes in the eight patients were death (5), paraplegia (1), amputation (1), and uncomplicated recovery (1). The single patient who made an uncomplicated recovery had the shortest delay from presentation to revascularization of only 2 1/4 hours. Acute aortic occlusion rivals aortic rupture as a vascular emergency and demands immediate operative intervention.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
10/18. Respiratory tract infection and anaesthesia. haemophilus influenzae pneumonia that developed under anaesthesia.A 2-year-old boy with symptoms of a minor upper respiratory tract infection developed haemophilus influenzae pneumonia that presented as hypoxaemia under anaesthesia for minor emergency surgery. The patient required 72 hours of mechanical ventilation in an intensive care unit after the anaesthetic and thereafter made an uneventful recovery. The value of pre-operative chest radiology and the possible contributory effect of anaesthesia are discussed.- - - - - - - - - - ranking = 10keywords = anaesthesia (Clic here for more details about this article) |
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