Canadian journal of anaesthesia = Journal canadien d'anesthésie
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Multicenter Study
DNR directives are established early in mechanically ventilated intensive care unit patients.
Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients. ⋯ One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.
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Administration of sc morphine has been recommended two hours after the end of iv morphine titration in the postanesthesia care unit (PACU), but in some cases patients complain of pain earlier than this. We assessed pain after the end of iv morphine titration and studied the characteristics of patients who needed rescue sc morphine. ⋯ Sedation during titration and an initial VAS > or = 60 are characteristics of the patients who require rescue (less than two hours) sc morphine after iv morphine titration.
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The 2003 ASA Practice Guidelines for Management of the Difficult Airway suggest the early use of the Laryngeal Mask Airway and Combitube as rescue airway devices in the cannot ventilate-cannot intubate situation, switching the focus from laryngoscopy and intubation to ventilation and oxygenation. The Practice Guidelines are not intended as standards but as recommendations. Multiple new alternative airway devices were described in the last ten years. The Laryngeal Tube (LT) is a new Food and Drug Administration approved supraglottic airway device. The device is in use in Europe since 1999 and in the United States since 2002. ⋯ In these clinical situations of unexpected difficult airway with significant periglottic obstruction the LT provided adequate ventilation after the first insertion. The LT may complement the laryngeal mask airway in difficult airway management. Further research is needed to define the role of the LT in the management of difficult airways.
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Case Reports
Emergency gum elastic bougie-assisted tracheal intubation in four patients with upper airway distortion.
The gum elastic bougie (GEB) has been in use for a long time and allows tracheal intubation in most cases of difficult direct laryngoscopy. Use of the GEB when anatomical landmarks of the upper airway are not recognizable has not been reported. We describe our experience of airway management with the GEB in cases of severe upper airway distortion. ⋯ The GEB can be a valuable tool in cases of difficult airway management caused by upper airway distortion. The lack of visualization of normal pharyngeal structures did not prevent the successful insertion of the GEB in the trachea in the four patients reported.
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To report the first use of spinal anesthesia for Cesarean section (CS) in a parturient with a long QT syndrome (LQTS) and an automatic implantable cardiac defibrillator (AICD). Although both general and epidural anesthesia have been described for CS in patients with LQTS, there are no previous case reports on the use of spinal anesthesia. The clinical features, diagnosis, treatment and anesthetic management of LQTS are discussed. ⋯ Spinal anesthesia was used safely for CS in this parturient with LQTS.