Intraoperative airway management by anesthesiology providers has evolved over the years to include many specialized devices and techniques that can have tremendous impact on the care of the perioperative critically ill patient. When perioperative patient care issues arise, anesthesiologists and perioperative critical care specialists should both be actively involved in a dialogue regarding many the relevant patient care issues, including any airway and respiratory function problems. Additionally, critical care specialists should be familiar with the use and potential complications of the increasingly diverse airway (and non-airway) tools and devices used by anesthesiologists in the operating room. The authors present a case report of a 66-year-old man who suffered repeated postoperative respiratory failure following an uncomplicated upper extremity orthopedic procedure. The patient developed unexplained, repeated postoperative respiratory failure that necessitated reintubation related to the accidental and unrecognized retention of a plastic tip extender from a Bullard fiber-optic laryngoscope. After transfer to the ICU, the patient continued to have significant respiratory distress requiring aggressive post-extubation noninvasive mechanical ventilation. The cause of this complication was not diagnosed by the anesthesiologist or the intensive care team throughout the course of this patient’s respiratory failure. Ultimately, the patient spontaneously expectorated the tip extender with rapid improvement in his respiratory function. This case highlights the importance of the dialogue that should occur between anesthesiologists and critical care specialists when unexpected and/or unexplained perioperative complications occur.
We describe multiple failed external defibrillation attempts via rescue defibrillation pads for ventricular fibrillation that occurred secondary to direct electrical current transmission through the pericardial sac from electrocautery during robot-assisted internal mammary harvest. Only after resumption of two-lung ventilation and decompression of the iatrogenic pneumothorax was the patient successfully defibrillated. Conditions necessary for robotic intrathoracic surgery may make defibrillation and resuscitation difficult if they become necessary.
Experience with invasive airway procedures may be difficult to obtain during residency training, and anesthesiologists may therefore be hesitant to use these life-saving techniques. We designed a prospective study to determine whether using embalmed cadavers to teach percutaneous cricothyrotomy (PC), retrograde intubation (RI), and fiberoptic intubation to anesthesiology residents would improve their perceived procedural confidence and ability. After demonstration of these techniques by experienced attending physicians, residents were allowed to practice, with instructor guidance, on the cadavers. Residents completed surveys before and after the workshop about their perceived confidence using these techniques. Eighteen residents attended the lecture workshop and completed surveys. The number of residents who reported that they would use PC increased from 0% to 78% (P
Introduction: Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at risk for sepsis during their hospitalization; however, it is not clear how this diagnosis may affect the risk of mortality and their length of stay. Hypothesis: The diagnosis of sepsis in patients with aSAH increases mortality and length of stay compared to patients with aSAH who are not diagnosed with sepsis. Methods: The University Healthcare Consortium (UHC) database was queried from 04/2008 to 06/2011 for all patients with primary ICD-9 diagnosis codes of aSAH. Inpatient mortality, ICU length of stay and hospital length of stay for these patients were then compared based on whether they had a secondary diagnosis of sepsis or other related conditions, including septicemia, severe sepsis, and septic shock, during their admission. Results: Using the UHC database, 33849 patients with aSAH were located. Of these patients, approximately 2080 (6.1%) also had a sepsis-related diagnosis. When these aSAH patients were compared to patients with sepsis-related diagnoses, the mortality was increased from 17.9% to 45.3% (p<0.0001), ICU LOS was increased from a mean of 9.6 days to 18.8 days (p<0.0001), and hospital LOS was increased from a mean of 13.4 days to 28.2 days (p<0.0001). Conclusions: Sepsis was associated with a statistically significant increase in mortality, ICU LOS and hospital LOS in patients with aneurysmal SAH. Additional studies are warranted to determine risk factors for the poor outcomes observed in these patients and to determine whether the utilization of specific care measures and bundles may improves these outcomes.
Spinal cord stimulators are most often placed through a percutaneous approach using minimal sedation and local anesthesia to facilitate intraoperative testing. However, when leads need to be placed using a laminectomy incision additional anesthesia is required which can complicate intraoperative testing. There is no consensus as to the best anesthetic choice when laminectomy-placed leads are required.We present 2 cases where spinal cord stimulator leads were implanted through a surgical laminectomy under sedation using dexmedetomidine infusion and local anesthesia to provide a cooperative patient for intraoperative testing.Patient #1: A 40-year-old female with Complex Regional Pain Syndrome secondary to an automobile accident who had good pain control with a spinal cord stimulator until a lead fracture resulted in loss of stimulation. She required a laminectomy-placed lead which was implanted under dexmedetomidine infusion and local anesthesia. Patient #2: A 54-year-old female with Failed Back Syndrome who had good pain control until a lead fracture resulted in loss of stimulation. She underwent a laminectomy-placed lead, new battery pocket, and removal of the old system under a dexmedetomidine infusion and local anesthesia.Report of only 2 cases.The anesthetic management from a laminectomy-placed spinal cord stimulator can present a difficult choice. A general anesthetic or even deep sedation can provide good operative conditions but limits intraoperative testing or in the case of deep sedation risks losing the airway in the prone position. On the other hand, minimal sedation, which facilitates intraoperative testing, can make the surgical procedure extremely uncomfortable or even unbearable. Dexmedetomidine infusion and local anesthesia provide sedation for the operative portions while rendering the patient alert and cooperative during intraoperative testing.
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