Overview of Hypothermia, Its Role in Neuroprotection, and the Application of Prophylactic Hypothermia in Traumatic Brain Injury.

The current standard of practice is to maintain normothermia in traumatic brain injury (TBI) patients despite the theoretical benefits of hypothermia and numerous animal studies with promising results. While targeted temperature management or induced hypothermia to support neurological function is recommended for a select patient population postcardiac arrest, similar guidelines have not been instituted for TBI. In this review, we will examine the pathophysiology of TBI and discuss the benefits and risks of induced hypothermia in this patient population. In addition, we provide an overview of the largest randomized controlled trials testing-induced hypothermia. Our literature review on hypothermia returned a myriad of studies and trials, many of which have inconclusive results. The aim of this review was to recognize the effects of hypothermia, summarize the latest trials, address the inconsistencies, and discuss future directions for the study of hypothermia in TBI.

Fibreoptic Orotracheal Intubation of Obese Patients Using Parker Flex-Tip vs. Standard Endotracheal Tube.

OBJECTIVE: Advancement of the endotracheal tube through a fibreoptic scope can sometimes prove to be challenging in obese patients. The Parker Flex-Tip endotracheal tube was developed with a curved and tapered distal tip to facilitate easier placement in the trachea. This study examined the use of the Parker Flex-Tip tube as compared to standard endotracheal tubes in patients with a body mass index of 30 or greater. METHODS: Sixty patients undergoing surgery requiring general anaesthesia were randomised into two groups. Using the fibreoptic scope, one group was intubated with the Parker Flex-Tip tube and the other group with a standard polyvinyl Portex tube. The time for intubation and the number of attempts required to place the endotracheal tube were measured and recorded. RESULTS: Using the Mann-Whitney U rank sum test, the median time needed for intubation with the two types of endotracheal tubes did not show a significant difference. The chi-square analyses were conducted for the number of attempts needed to place the endotracheal tubes, which also did not demonstrate any significant difference. CONCLUSIONS: Parker Flex-Tip endotracheal tube was not superior to the standard endotracheal tubes for fibreoptic intubation in obese patients.

The use of podcast videos for airway skills.

BACKGROUND: For a procedure-driven specialty such as anaesthesiology, hands-on training has always been the primary method of teaching airway skills. Although this method will always be a necessary component, the current generation of learners tend to gravitate toward media as educational sources. We propose that the addition of watching a series of podcast videos on airway management will further enhance the medical student's procedural skills. METHODS: A total of 34 medical students scheduled for an anaesthesia rotation were randomised into two groups. Both groups received the conventional one-to-one hands-on training on airway skills in the operating room; however, the study group received an additional series of podcast videos on airway equipment, mask ventilation and intubation. At the end of the rotation, all of the students were given an objective structured clinical examination (OSCE) on a mannequin. RESULTS: The study group who received the podcasts significantly out-performed the control group on the OSCE (p = 0.003). The mean score for the podcast video group was 94.4%, versus 76.5% in the control group. Commonly missed steps by the control group included checking the endotracheal tube balloon before intubation, taping the eyes and auscultation of the epigastrium and lungs. DISCUSSION: Our results showed that supplementing conventional hands-on training with contemporary channels such as podcast videos improved learners' procedural skills. The media format was relatable for these modern learners and provided the added benefit of self-paced learning. Overall, the podcast videos made a positive contribution to students learning airway techniques.

Teaching Anesthesiology Residents How to Obtain Informed Consent.

BACKGROUND: Although obtaining medical consent is an important skill, many residents may have knowledge gaps in understanding key concepts of informed consent or may lack awareness of serious procedural risks. The objective of this study was to see if formal education makes a difference in anesthesiology residents' ability to obtain an informed consent. METHODS: Thirty-four first-year anesthesiology residents (CA1s) were randomized into either a control group or study group. The control group learned how to obtain consent for general anesthesia the current way, which is by observing senior residents or faculty. The study group received additional formal education, which included a video, a narrated lecture, and a quiz. Afterwards, both groups were observed obtaining informed consent on patients receiving general anesthesia. The investigators used a checklist consisting of 10 important items that the resident had to fulfill for a proper informed consent. To minimize bias, neither the control group nor the study group was shown the checklist. RESULTS: Overall, the study group did significantly better than the control group in fulfilling the 10 items on the checklist (median 0.90 vs 0.70; P < .001). There were statistical differences on 4 key components: identifying all persons on the anesthesia team (76.5% vs 5.9%, P < .0001), explaining why general anesthesia is necessary (82.4% vs 35.3%, P < .0134), explaining the risks and benefits of general anesthesia (94.1% vs 47.1%, P < .0066), and discussing the risks and benefits of blood transfusion (70.59% vs 29.4%, P < .0381). CONCLUSIONS: This study shows that formal instruction on informed consent enhances residents' ability to obtain an informed consent.

Predictors of difficult epidural placement in pregnant women: A trainees' perspective.

BACKGROUND AND AIMS: Epidural analgesia is believed to be the most difficult technique to learn for a trainee. The reason for this is not only inexperience of the provider and the complexity of the technique but also patient factors like obesity, spinal deformity and others which makes the epidural placement difficult. The aim of this study was to evaluate some of the common risk factors for difficult epidural placement as perceived by the anesthesia providers during training, with varying level of experience. MATERIAL AND METHODS: This prospective observational study includes patients who received epidural placement for labor analgesia. Data recorded on these patients included age, height, weight, body mass index (BMI), ease of palpation of the spinous process, level of epidural placement, number of attempts, time taken for epidural placement and experience of the provider. The association between the variables were assessed using logistic regression for first attempt success and Cox proportional hazard ratio for time to epidural placement. RESULTS: A total of 373 patients received epidural placement for labor analgesia. The mean BMI at the time of placement was 34. The first attempt success rate for the placement of epidural was 67% (n = 273). Women with well palpable spinous process were 3.3 times more likely to have a successful first attempt placement irrespective of the provider experience or BMI [3.39 (1.77-6.51), P < 0.001]. The time to placement was shorter in patients with good anatomical landmarks [1.58 (1.20-2.07), P < 0.001) and when performed by a trainee who had performed a minimum of 20 epidural procedures [1.57 (1.26-1.94), P < 0.001). CONCLUSION: Inability to palpate the spinous process contributes to multiple attempts at epidural placement when performed by a trainee.

Anesthetic management of a large mediastinal mass for tracheal stent placement / Manejo anestésico de grande massa mediastinal para a colocação de stent traqueal

ABSTRACT The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

RESUMO O manejo anestésico de pacientes com grandes massas situadas no mediastino pode ser complicado por causa dos efeitos da pressão da massa sobre as vias aéreas ou grandes vasos. Relatamos o manejo anestésico bem-sucedido de uma paciente de 64 anos com uma grande massa mediastinal que invadiu os grandes vasos e comprimiu a traqueia. Um stent traqueal foi colocado para aliviar a compressão da traqueia, sob anestesia geral. A ventilação espontânea foi mantida durante o período perioperatório com o uso de uma máscara laríngea clássica. Discutimos a utilidade da máscara laríngea para o manejo da colocação de stent traqueal em pacientes com massas situadas no mediastino.

Anesthetic management of a large mediastinal mass for tracheal stent placement.

The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

[A unique case of pulmonary artery catheter bleeding from the oximetry connection port]. / Caso único de sangramento pela porta de conexão do cateter de artéria pulmonar ao módulo de oximetria.

Pulmonary artery catheter is an invasive monitor usually placed in high-risk cardiac surgical patients to optimize the cardiac functions. We present this case of blood oozing from the oximetry connection port of the pulmonary artery catheter that resulted in the inability to monitor continuous cardiac output requiring replacement of the catheter. The cause of this abnormal bleeding was later confirmed to be due to a manufacturing defect.

A unique case of pulmonary artery catheter bleeding from the oximetry connection port / Caso único de sangramento pela porta de conexão do cateter de artéria pulmonar ao módulo de oximetria / Caso único de sangrado por el puerto de conexión del catéter de arteria pulmonar al módulo de oximetría

Pulmonary artery catheter is an invasive monitor usually placed in high-risk cardiac surgical patients to optimize the cardiac functions. We present this case of blood oozing from the oximetry connection port of the pulmonary artery catheter that resulted in the inability to monitor continuous cardiac output requiring replacement of the catheter. The cause of this abnormal bleeding was later confirmed to be due to a manufacturing defect.

O cateter de artéria pulmonar é um monitor invasivo geralmente usado durante cirurgias cardíacas em pacientes de alto risco para aprimorar as funções cardíacas. Apresen-tamos o caso de escoamento de sangue pela porta de conexão do cateter de artéria pulmonar para oximetria que resultou na impossibilidade de monitorar o débito cardíaco contínuo e na substituição do cateter. A causa do sangramento anormal foi posteriormente confirmada como um defeito de fabricação.

El catéter de arteria pulmonar es un monitor invasivo generalmente usado durante cirugías cardíacas en pacientes de alto riesgo para optimizar las funciones cardíacas. Presen-tamos el caso de entrada de sangre por el puerto de conexión del catéter de arteria pulmonar para oximetría, trayendo como resultado la imposibilidad de monitorizar el gasto cardíaco continuo y, por ende, la sustitución del catéter. La causa del sangrado anormal fue posteriormente confirmada como un defecto de fabricación.

The effects of mild perioperative hypothermia on blood loss and transfusion requirement.

BACKGROUND: Anesthetic-induced hypothermia is known to reduce platelet function and impair enzymes of the coagulation cascade. The objective of this meta-analysis and systematic review was to evaluate the hypothesis that mild perioperative hypothermia increases surgical blood loss and transfusion requirement. METHODS: The authors conducted a systematic search of published randomized trials that compared blood loss and/or transfusion requirements in normothermic and mildly hypothermic (34-36 degrees C) surgical patients. Results are expressed as a ratio of the means or relative risks and 95% confidence intervals (CI); P < 0.05 was considered statistically significant. RESULTS: Fourteen studies were included in analysis of blood loss, and 10 in the transfusion analysis. The median (quartiles) temperature difference between the normothermic and hypothermic patients among studies was 0.85 degrees C (0.60 degrees C versus 1.1 degrees C). The ratio of geometric means of total blood loss in the normothermic and hypothermic patients was 0.84 (0.74 versus 0.96), P = 0.009. Normothermia also reduced transfusion requirement, with an overall estimated relative risk of 0.78 (95% CI 0.63, 0.97), P = 0.027. CONCLUSION: Even mild hypothermia (<1 degree C) significantly increases blood loss by approximately 16% (4-26%) and increases the relative risk for transfusion by approximately 22% (3-37%). Maintaining perioperative normothermia reduces blood loss and transfusion requirement by clinically important amounts.