Optimization of Endotracheal Tube Cuff Pressure by Monitoring CO2 Levels in the Subglottic Space in Mechanically Ventilated Patients: A Randomized Controlled Trial.

BACKGROUND: Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. METHODS: This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. RESULTS: Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). CONCLUSIONS: This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group. Thus, the use of automatic cuff pressure control based on subglottic measurements of CO2 levels is an effective method for ETT cuff pressure optimization. The method is safe and can be easily utilized with any intubated patient.

[Apnea after general anesthesia for revision of uterus in parturient with K-variant of the butyrylcholinesterase enzyme (BChE)].

A 30 years old parturient was admitted to the operating theatre for revision of uterus after spontaneous labor because of hemorrhage. She underwent general anesthesia induced by rapid sequence induction (RSI) technique. Apnea for 45 minutes was observed after succinylcholine administration. Biochemistry laboratory tests from the operation day showed very low butyrylcholinesterase activity, and a repeated test after one month showed normal enzyme activity and inhibitors within the normal range. Genetic tests revealed heterozygosity for the K variant of BChE. This may explain the increased sensitivity to succinylcholine during pregnancy.

Do waking salivary cortisol levels correlate with anesthesiologist's job involvement?

Anesthetists' work carries great responsibility and can be very stressful. Cognitive appraisal plays a central role in stress responses; however, little is known about the relationship between stress appraisal and biological markers of stress, particularly among anesthesiologists. Stress response may be associated with increased levels of systemic cortisol, which can be conveniently measured in saliva and used as a marker for the extent of stress. The objective of this study was to examine the correlation between work-related cognitive variables and waking salivary cortisol, a possible stress marker, in anesthesiologists. Thirty-eight anesthesiologists were assessed for work-related thought intrusions and perceived "mental distance" between themselves and their work, using the pictorial representation of illness self-measure (PRISM), and underwent an implicit association test reflecting implicit job-stress associations. Salivary cortisol was measured twice upon awakening and an hour later, in saliva samples, using a kit based on chemoluminescence competition assay. Only implicit job-stress associations were correlated with waking cortisol (r = 0.35, p < 0.05). Furthermore, high implicit job-stress was related to elevated cortisol only among anesthesiologists reporting large "mental distance" from work, which may represent limited job involvement related to burnout. Anesthesiologists with a low degree of job involvement who have high implicit job-stress associations have higher levels of waking salivary cortisol. Further studies are necessary to assess the impact of stress management techniques on anesthesiologists' personal and professional behavior as well as on the quality of medical care.

Office-based ambulatory sedation--the use of the airway protector system during oral surgery: a prospective audit of the first 100 patients.

PURPOSE: To evaluate the efficacy of the "Airway Protector System" (APS), a simple homemade device used for airway control during office-based dental sedation. PATIENTS AND METHODS: A prospective audit was performed in 100 severely dental phobic patients submitted to dental treatment in a dentist office under propofol sedation. RESULTS: Sixty-eight females and 32 males were enrolled in this study. The mean age was 45 +/- 7 years (range, 18 to 67 years). A clear airway was obtained in 94 patients. Partial airway obstruction was observed in 4 patients but manual lifting of the jaw was enough to free the partial obstruction and dental treatment was uneventfully conducted. In 2 patients, the APS had to be converted to formal nasotracheal intubation because jaw-lifting maneuvers did not adequately relieve a partial airway obstruction. Sore throat was reported in 56 patients. In 27 cases, the patients rated the complaint as severe. No patient required a chest x-ray after sedation, as there was no clinical evidence of any pulmonary complication including dyspnea, cough, or fever. CONCLUSION: We suggest that the concomitant use of a homemade cuffed nasopharyngeal airway with continuous suction facilitates airway control during deep levels of office-based sedation for dental treatment in severely dental phobic patients.

Patients' self-criticism is a stronger predictor of physician's evaluation of prognosis than pain diagnosis or severity in chronic pain patients.

UNLABELLED: The experience of pain is influenced by patients' personality, social and cultural background, and patient-doctor interaction. This study examines the role of self-reported pain, pain diagnosis, age, gender, depression, and the personality trait of self-criticism (defined as individuals' tendency to set unrealistically high self-standards and to adopt a punitive stance toward one's self), in determining physicians' view of expected prognosis in response to chronic pain management. Before the first visit to a tertiary chronic pain clinic, patients provided information regarding their perceived pain, depression, and self-criticism. Immediately subsequent to the visit, physicians' evaluated expected prognosis. Participating physicians were blinded to the patient's psychosocial variables collected. Sixty-four patients with chronic pain (34 women and 30 men) with various diagnoses were included. Patients' age, gender, pain diagnosis, self-reported pain, and depression did not significantly correlate with physician's estimation of expected prognosis. In contrast, patients' self-criticism emerged as an independent predictor of physicians' pessimism regarding outcome. Thus, in the chronic pain clinic setting, patients' personality, rather than self-reported pain experience, determines doctor's clinical judgment of expected prognosis. PERSPECTIVE: Chronic pain is a multimodal negative experience that is determined by physiological, cognitive, personological, and interpersonal factors. In line with this observation, we found patients' personality, specifically, their self-criticism, determines physicians' clinical judgment of expected prognosis.

Can intensive care physicians safely perform percutaneous dilational tracheostomy? An analysis of 207 cases.

BACKGROUND: Percutaneous tracheostomy has largely replaced surgical tracheostomy in the intensive care unit setting. Although it seems logical that surgeons continue to do tracheostomies, anesthesiologists and intensive care specialists are familiar with airway control and guide wire techniques and could replace surgeons in the performance of PDT. OBJECTIVES: To assess the safety and effectiveness of bedside PDT in the ICU. METHODS: We conducted a retrospective chart review of 207 patients in the ICU who underwent PDT by an intensive care physician. RESULTS: Subcutaneous emphysema without pneumothorax occurred in one patient. Four patients underwent surgical revision following PDT. Early bleeding (during the first 48 hours following the procedure) was the indication in two patients and late bleeding, on the 10th post-PDT day, in one. In one case PDT was converted to surgical tracheostomy due to inadvertent early decannulation. There was one death directly related to the procedure, due to an unrecognized paratracheal insertion of the tracheostomy tube followed by mechanical ventilation, which led to bilateral pneumothorax, pneumomediastinum and cardio-circulatory collapse. No infectious complications were seen at the stoma site or surrounding tissues. CONCLUSIONS: PDT by intensive care physicians appears to be safe and should be included in the curriculum of intensive care residency.

Anesthetic considerations during percutaneous nephrolithotomy.

STUDY OBJECTIVE: To assess anesthesia-related complications during and following percutaneous nephrolithotomy (PCNL) for staghorn stones. DESIGN: Prospective study and a detailed case report. SETTING: Medical center in southern Israel. PATIENTS: 20 consecutive patients undergoing PCNL for staghorn stones. INTERVENTIONS: All patients underwent PCNL during general anesthesia. MEASUREMENTS: Duration of surgery, esophageal temperature, hemoglobin (Hb) concentration, and requirements for blood transfusion, mean volume of irrigation fluid, and serum sodium and potassium concentration were recorded. MAIN RESULTS: Mean age was 50.7 +/- 14.9 y (range, 26-76 y). Mean duration of the procedure was 120.0 +/- 42.5 min (range, 75-240 min). Mean volume of irrigation fluid was 34.1 +/- 15.3 L (range, 18-80 L). There was a significant decrease in Hb concentration from 13.7 +/- 1.71 to 12.2 +/- 1.4 g/dL, but no patient required blood transfusion. There was a statistically significant reduction in esophageal temperature from 36.4 degrees C +/- 0.32 degrees C to 35.2 degrees C +/- 0.5 degrees C. There were no significant changes in sodium or potassium concentration before or after PCNL. CONCLUSIONS: Anesthesia during PCNL for staghorn stones is a challenge because of the possibility of fluid absorption, dilutional anemia, hypothermia, or significant blood loss.

The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right.

BACKGROUND CONTEXT: It is a common practice to the link low back pain with protruding disc even when neurological signs are absent. Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked. PURPOSE: To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits. METHODS: Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration. RESULTS: The mean baseline VAS pain score was 7.8 +/- 1.77 (range 5-10). Thirty minutes after infiltration, the mean VAS score was 1.3 +/- 1.76 (median 0.000E+00 with an average deviation from median = 1.30) (P = 0.0002). Forty-six patients had a VAS score ranging from 0 to 3, 8 weeks after the fluoroscopic guided infiltration. There were no serious complications after treatment. An unanticipated motor block that required hospitalization was seen in four patients, lasting from 12 to 36 h. CONCLUSIONS: Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.

Phenol neurolysis for severe chronic nonmalignant pain: is the old also obsolete?

OBJECTIVE: Our purpose was to reassess the effectiveness of phenol 4% in aqueous solution for neurolysis in patients with severe chronic nonmalignant pain syndromes who did not achieve adequate pain control (visual analog scale [VAS]

Terlipressin facilitates transport of septic patients treated with norepinephrine.

BACKGROUND: Transport of hemodynamic unstable septic patients for diagnostic or therapeutic interventions outside the intensive care unit is complex but sometimes contributes to increasing the chance of survival. OBJECTIVES: To report our experience with terlipressin treatment for facilitation of transport to distant facilities for diagnostic or therapeutic procedures in septic patients treated with norepinephrine. METHODS: We conducted a retrospective analysis of the records of our ICU, identifying the patients with septic shock who required norepinephrine for hemodynamic support. RESULTS: Terlipressin was given to 30 septic shock patients (15 females and 15 males) who were on high dose norepinephrine (10 microg/min or more) in order to facilitate their transport outside the ICU. The dose of terlipressin ranged from 1 to 4 mg, with a mean of 2.13+/-0.68 mg. The dose of norepinephrine needed to maintain systolic blood pressure above 100 mmHg decreased following terlipressin administration, from 21.9+/-10.4 microg/min (range 5-52 microg/min) to 1.0+/-1.95 (range 0-10) (P < 0.001). No patients required norepinephrine dose adjustment during transport. No serious complications or overshoot in blood pressure values were observed following terlipressin administration. Acrocyanosis occurred only in eight patients receiving more than 1 mg of the drug. The overall mortality rate was 50%. CONCLUSIONS: Our data suggest that terlipressin is effective in septic shock. Because it is long-acting and necessitates less titration it might be indicated for patient transportation.

Bivalirudin for anticoagulation in mechanical aortic valve replacement and heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a potentially serious syndrome. Since there are some alternatives to treatment with heparin in patients who develop HIT, the decision as to which to use should be based on renal and hepatic function, drug availability and the available monitoring resources. We report a patient who received heparin for mechanical aortic valve replacement. Her clinical course was complicated by HIT, which was treated initially by danaparoid. The syndrome progressed with new thrombotic complications, and eventually was treated successfully by bivalirudin (Angiomax; Medison Pharma Ltd, Petach Tikva, Israel) for 9 days. We propose that treatment with bivalirudin for several days is a safe and effective alternative to heparin therapy in patients who develop HIT.

Controlled-release oxycodone-induced seizures.

BACKGROUND: The use of the opioid oxycodone hydrochloride in the management of chronic pain is gaining popularity principally because of its tolerability. However, opioid-related seizure in patients with epilepsy or other conditions that may decrease seizure threshold has been described in the literature; in particular, oxycodone has been associated with seizure in a patient with acute renal failure. OBJECTIVE: The aim of this article was to report a patient with a history of seizures but normal renal and hepatic function who developed seizure on 2 occasions after oxycodone ingestion. METHODS: A 54-year-old male patient presented with a history of tonic-clonic seizures that developed immediately after intracranial surgery. Long-term treatment with carbamazepine 400 mg QD was started, and the patient was free of convulsions for approximately 7 years. The patient presented to us with severe headache that was nonresponsive to an NSAID and the opiate agonist tramadol. Treatment with controlled-release (CR) oxycodone and tramadol drops (50 mg QID if necessary) was started, and tonic-clonic seizures developed 3 days later. RESULTS: Based on laboratory analysis, the patient had normal renal and hepatic function. On discontinuation of oxycodone treatment, the seizures resolved. However, due to effective pain relief with oxycodone, the patient decided to continue treatment, and seizures recurred. Carbamazepine was then administered 4 hours before oxycodone dosing, which allowed continuation of treatment without seizure. CONCLUSIONS: A patient with a history of seizures controlled with long-term carbamazepine therapy developed seizures when he started treatment with oxycodone CR at recommended doses. Oxycodone CR should be used with extreme caution in patients with epilepsy or other conditions that may decrease seizure threshold.

Is penile block better than caudal epidural block for postcircumcision analgesia?

PURPOSE: To compare caudal and penile block for post-operative analgesia in children undergoing circumcision with respect to efficacy, complication rates, and parental satisfaction. METHODS: The study population consisted of 100 ASA 1 and 2 boys aged 3 to 8 years who were undergoing circumcision for religious reasons. In all participants, inhalation anesthesia was administered with oxygen : nitrous oxide (1 : 2) and halothane. The participants were allocated randomly into two groups of 50 children each. Group 1 received penile block and Group 2 caudal block. The penile block was achieved by injecting bupivacaine into the two compartments of the subpubic space, with an additional ventral infiltration of a small volume of bupivacaine along the raphe of the penis. For caudal block, 1 ml.kg(-1) body weight of 0.25% bupivacaine was administered. RESULTS: Penile block shortened the induction-incision time and enabled earlier discharge home compared with caudal block. One patient undergoing penile block and nine patients undergoing caudal block vomited. CONCLUSIONS: Penile and caudal block are equally effective for postcircumcision analgesia and neither is associated with serious complications. Anesthesiologist preference should be the deciding factor in choosing one technique over the other.

Urinary excretion of vitamin A in critically ill patients complicated with acute renal failure.

OBJECTIVE: Study the possible excretion of vitamin A in urine of critically ill patients complicated with acute renal failure. PATIENTS AND METHODS: Nine Intensive Care Unit patients, age 71.2 +/- 15.7 (mean +/- SD) with acute renal failure were studied. Urinary retinol, creatinine, protein, albumin, and serum creatinine were measured. RESULTS: All patients excreted retinol in urine; individual values ranged from 0.007 to 0.379 micromol retinol/mmol creatinine. There was no correlation of urinary retinol/creatinine ratio with serum creatinine or with urinary protein/creatinine and albumin/creatinine ratios. CONCLUSION: Excretion of retinol in urine may be indicative of acute renal failure in critically ill patients.

Helmet noninvasive ventilation for weaning from mechanical ventilation.

We saw a patient who presented with carbon dioxide narcosis and acute respiratory failure due to an exacerbation of chronic obstructive pulmonary disease. We intubated and 12 hours later he had recovered consciousness and could cooperate with noninvasive ventilation, at which point we extubated and used a helmet to provide noninvasive positive-pressure ventilation in assist/control mode, and then during the ventilator-weaning process, pressure support, and finally continuous positive airway pressure. The patient had no complications from the helmet, and he was discharged from intensive care 48 hours after helmet ventilation was initiated. Helmet noninvasive ventilation is a potentially valuable ventilator-weaning method for certain patients.

Emergency percutaneous tracheostomy is feasable in experienced hands.

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.

Fatal metabolic acidosis caused by thiamine deficiency.

Acute thiamine deficiency, an uncommon cause of hemodynamic instability in Western countries, may be manifested by acute heart failure and neurological deficits. Severe metabolic acidosis is one of its least recognized features. We present a report of foreign workers who complained of weakness and lower limb edema and were found to have acute thiamine deficiency. One died of refractory metabolic acidosis and shock, and the diagnosis was reached post mortem. Thiamine deficiency should be considered in every case of severe lactic acidosis without an obvious cause, especially in high-risk populations (malnourished, alcoholics, Far-East workers, etc). Whenever it is suspected, empiric treatment with thiamine should be initiated immediately. Physicians who care for populations at risk should be familiar with the clinical spectrum of nutritional deficits, and monitor the nutritional habits of these patients carefully. The treatment is inexpensive and devoid of adverse effects. Moreover, delaying thiamine administration in patients with deficiency may cause severe life-threatening metabolic acidosis and affect recovery. The prophylactic use of thiamine in a high-risk population, even before blood levels are received, may be cost effective.