Trauma Anesthesia
Back to topTriple Maneuver
It is essential that one apply the pressure at the proper location to correct laryngospasm. One MUST FEEL THE BASE OF THE SKULL SUPERIORLY, THE MASTOID PROCESS POSTERIORLY, AND THE CORONOID PROCESS OF THE MANDIBLE ANTERIORLY. any lower than that and it doesn’t work. Usually the pressure point is covered by the ear lobes. Pressure is directed inward and must be done FIRMLY. One cannot be a wimp about it!! Applying the same pressure at the angle of the jaw, ie jaw thrust, does not resolve laryngospasm.I do the maneuver immediately after extubating the trachea, since I cannot tell, nor can anyone else whether the patient is in laryngospasm just by looking at them, unless they are vigorously breathing and mist (fog) is entering the mask. Patients can look like they are breathing, but no gas may be moving past the cords. It’s such an easy thing to do and corrects airway obstruction from both laryngospasm and the tongue falling back against the posterior pharyngeal wall. Why not do it after every extubation?? The patients won’t remember it, and there are no serious complications from doing so.Why does it work?? That question I cannot answer with confidence. However, it is not due to pain alone, since pain instituted in other areas, such as abdominal or rectal pain will induce laryngospasm. I believe that the maneuver activates the 9th and 10th cranial nerves, but I cannot prove that theory.As stated above, there is no complication from doing this. As I state, I have done it many thousands of times and it has never failed. I appreciate that nothing is perfect, but this comes as close to perfect as one can get provided it is done correctly!! Skeptics should do it 200 times and they will become confirmed believers. And patients will be spared episodes of hypoxemia, or worse, negative pressure pulmonary edema. Phil Larson
Back to topPlanes of Anesthesia
Back to topEmergency and Trauma Checklist
Checklist for Emergency and Trauma Anesthesia Cases Anesthesiology Thank you Brian, this seems to be a nice approach. Do you use any method to improve the crit before the procedure – like HuEPO, iron reposition, danazol, or sth like that? claudia 2006/3/14, Brian Woodcock <bwudcock@med.umich.edu>: > I think that using acute normovolemic hemodilution may not actually be > worthwhile in reducing blood transfusion, mathematically you have to be > extreme to have a chance of reducing transfusion. > > Consensus conference on autologous transfusion. Acute normovolaemic > haemodilution. Transfusion. 36(7):640-3, 1996 Jul. > > “ANH is a relatively cheap and logistically straightforward method of > autologous transfusion which is attractive in that it may be applied to > a wide cross-section of patients, many of whom will not be suitable for > pre-deposit. There are, however, concerns about the safety of the > procedure, and doubts have been expressed about its efficacy in reducing > allogeneic transfusion requirements and, therefore, its > cost-effectiveness. Assessment of the value of the procedure is hampered > by the lack of large scale prospective, controlled trials. In the > present state of knowledge it seems that ANH is most likely to be safe, > efficacious and cost-effective when undertaken aggressively (target > haematocrit < 0.20) in otherwise healthy, young patients undergoing > elective surgery with large expected blood losses. [References: 45]” > > Does acute normovolemic hemodilution reduce perioperative allogeneic > transfusion? A meta-analysis. The International Study of Perioperative > Transfusion. Anesthesia & Analgesia. 86(1):9-15, 1998 > > “The objective of this study was to systematically review the > literature and to statistically summarize the evidence evaluating acute > normovolemic hemodilution (ANH). Prospective, randomized, controlled > trials of ANH that reported either the proportion of patients exposed to > allogeneic blood or the units of allogeneic blood transfused were > included. All types and languages of publication were eligible. Of 1573 > identified publications, 24 trials
(containing a total of 1218 patients) > were included in the meta-analysis. When all trials were pooled, ANH > reduced the likelihood of exposure to allogeneic blood (odds ratio [OR] > 0.31, 95% confidence interval [CI] 0.15, 0.62) and the total units of > allogeneic blood transfused (weighted mean difference [WMD] -2.22 U, 95% > CI -3.57, -0.86). However, there was marked heterogeneity of the > results. In trials using a protocol to guide perioperative transfusion, > ANH failed to reduce either the likelihood of transfusion (OR 0.64, 95% > CI 0.31, 1.31) or the units administered (WMD -0.25 U, 95% CI -0.60, > 0.10). Adverse events were incompletely reported. It is possible that > biased experimental design is, in part, responsible for the reported > efficacy of this technique. Implications: after a systematic literature > review, 24 randomized trials examining the role of acute normovolemic > hemodilution were identified, pooled, and summarized using statistical > techniques. Many studies reported an impressive reduction in blood > transfused. Closer examination suggests that these reductions in blood > exposure may be due to flawed study design.” > > However, WARNING; unsubstantiated personal observations approaching (I > seem to be doing this a lot recently), we do ANH for massive cardiac ops > where major bleeding is anticipated, particularly aortic reconstruction > involving the ascending and arch, or descending thoracic repairs. So we > give the blood back immediately after the protamine, so they get their > own platelets which have not been wrecked by passing through the CPB > pump. > > Our protocol is to take 2 units from the 9 french introducer in the > neck, this goes into a blood bag with 60ml of CPD, I usually try to get > good sized units 600 – 650 ml. You can weigh them to see how much you > have. I watch the hemodynamics while it comes off, if they look > hypovolemic I’ll speed up the peripheral IV with crystalloid, or colloid > if necessary. If it is a big patient with a good crit I might take 3 > units. > > You can predict the final crit by estimating blood volume (70ml/kg) > then new crit = (EBV-volume taken off) x crit/EBV. If the predicted > crit will be too low to go on CPB (they get further hemodiluted) then we > will give PRBC peripherally during or after the blood harvest. Remember > we are not trying to reduce transfusion by ANH, we are harvesting good > platelets to give back after CPB. > > Brian > > Brian Woodcock MB ChB, MRCP, FRCA I’ve been using normovolemic hemodilution quite a bit in the last years and I think it can be very usefull especially if the procedure is at high risk of bleeding and the starting hematocrit is over 36. My collegues, who think that a cardio patient has to be dry, take from 350 to 450 ml of blood before heparinization and give maximum of 500ml of colloids insted. I think an the other way that the cardiac output has to be mantained and a cardiac patient has not to be dry and so I give 3 times the volume of blood drawn away of cristalloides or the double of the amount of blood of colloides. Advantages: it lowers the risk of transfusion, and of bleeding (coagulation is better with fresh whole blood). And thinking about eythropietin and iron: Probably erithropoietin would be ok even if expensive (I stopped using it becouse the advantages/costs ratio was in my opinion not so high and becouse usually we see the patients just the day before the procedure); on the other side I would not use iron since it is one of the elements responsible of the reperfusion injury. Guido Panduri Anesthesiologist Ancona – Italy
Back to topAnaConDa
Sedation with volatile anesthetics (J Crit Care 2009;inpress soukup j, state of the art: sedation concepts with volatile) including the AnaConDa
Back to topAnesthesia for Endobronchial Ultrasound / Procedures
From: James DuCanto <jducanto@mac.com>