Critical care clinics
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In summary, the need to manipulate the airway in the pregnant patient requires careful consideration and substantial planning. Anatomic and physiologic changes of pregnancy, coexisting conditions, and the potential for aspiration all carry a risk of morbidity and, indeed, mortality. Preparation, including early and repeated airway evaluations throughout pregnancy and labor, is encouraged. ⋯ Equipment must be available and in good condition. Finally, proper education and review for individuals involved in the delivery of care on the labor floor are mandatory. Although it is not always possible to control the manner in which these patients present, it is usually possible to control the environment into which they present.
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Critical care clinics · Jul 2000
ReviewEmergent airway management. Indications and methods in the face of confounding conditions.
Optimal airway management requires an experienced caregiver, attention to detail, and knowledge of the patient's physiology. A variety of pharmacologic agents have proved useful in obtaining a secure airway and minimizing risk to the patient. Depending on the skills of the caregiver, oral intubation has become the preferred means of airway control in most patients. Advances in technique, equipment, and pharmacology have greatly improved the art of airway management; however, there is no substitute for an experienced clinician.
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Airway management in the pediatric patient requires an understanding and knowledge of the differences and characteristics unique to the child and infant. New and exciting techniques are currently being explored and developed for management of the pediatric airway. ⋯ Work continues to probe for methods and ways that will allow us to take care of infants and children better and to provide the safest and most effective means of delivering that care. No doubt, there will be more advances and exciting ideas to come that lead to better management of the pediatric airway.
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Critical care clinics · Jul 2000
ReviewEmergent management of the airway. New pharmacology and the control of comorbidities in cardiac disease, ischemia, and valvular heart disease.
Once it is decided that the patient in distress requires tracheal intubation, the primary goal is to secure the airway as quickly and safely as possible to assure adequate oxygenation and ventilation. The clinician should quickly review the patient's history, physical examination findings, and laboratory data to determine the presence of cardiovascular disease, assess intravascular volume status, and formulate a plan for induction of anesthesia. The stresses of hypoxia, hypercarbia, acidosis, and extreme fatigue result in near-maximal sympathetic outflow that is manifest as tachycardia, labile blood pressure, and increased myocardial contractility. ⋯ Most clinical studies have been performed in hemodynamically stable patients, so the routine dosages of sedative hypnotics should be reduced substantially and titrated to effect. An additional strategy is to treat significant hemodynamic perturbations with vasopressors, vasodilators, short-acting selective beta-1 blockers, and inotropic agents. The choice of vasoactive agent depends on the magnitude of the hemodynamic response and the presence of specific underlying cardiovascular pathology.
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Critical care clinics · Jul 2000
ReviewOrganization of personnel and resources for airway management in the hospital and office environment.
Good airway management depends on a system that emphasizes teamwork to expedite care and minimize errors. By understanding the accreditation and licensing requirements, appropriate personnel and equipment can be allocated along cost effective guidelines. Newer techniques for management of the difficult airway, such as the laryngeal mask airway (LMA; LMA North America, San Diego, CA) and flexible fiberoptic bronchoscope, provide alternatives to the emergency cricothyrotomy. A program of continuous quality improvement and clinical guidelines will enhance patient care and suggest intelligent use of airway resources.