Anesthesiology clinics of North America
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What have we learned so far from the Closed Claims database? For the most part, analysis of the claims made supports the generally held beliefs about the medico-legal risk of obstetrical anesthesia. However, the obstetric files do reveal a risk profile that differs significantly from the nonobstetric files. One of the most surprising observations was the large proportion of relatively "minor" injuries in the obstetric files in contrast to the nonobstetric files. ⋯ The uniqueness of the ASA Closed Claims database is that it reflects the consumer's perspective. This point can not be emphasized enough because one of the best measures of quality of care comes from the patient's perspective. What can help? Careful personal conduct Establish good rapport Involvement in prenatal education Early pre-anesthetic evaluation Provide realistic expectation Regularly review potential major and minor risks.
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In maternity units in which central neuraxial techniques are frequently used, newer methods of epidural drug delivery (continuous infusion, patient-controlled) are well established and combined spinal-epidural analgesia is commonly used. Continuous spinal analgesia has reemerged as a useful approach after accidental dural puncture. ⋯ PCIA is again under investigation because of the potent antinociceptive effects of the short-acting mu-opioid agonist, remifentanil. The premixing of nitrous oxide and a subanesthetic concentration of volatile anesthetic for patient-controlled administration has been tested under control of midwifery staff and without direct medical supervision.
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Anesthesiol Clin North America · Dec 2002
ReviewTraumatic complications of intubation and other airway management procedures.
Complications arising from intubation and other airway management procedures can have significant morbidity and mortality risks. With the increasing interventional techniques employed by the anesthesiologist to acquire and maintain an airway, there is a potential for increasing airway injury. Awareness of the potential "difficult" airway and employing the appropriate techniques to maximize airway visualization can minimize the risk of these complications.
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Normal respiration involves a highly detailed neurophysiologic process that results in the exchange of inspired and expired air through various anatomic structures. An understanding of these structures is important to the clinician involved in maintaining or reestablishing the normal airway. The following anatomic discussion focuses on the features crucial for the establishment and maintenance of a tracheal airway.
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Understanding the differences between the infant upper airway and the adult upper airway is important in properly managing the infant and pediatric airway. Proper history and physical examination and selection of the appropriate endotracheal tubes, LMAs, and laryngoscopes are key to managing the normal infant and pediatric airway. The difficult infant and pediatric airway requires planning, preparation, and teamwork. ⋯ Congenital syndromes associated with difficult airways pose a unique set of challenges. Postoperative problems include postextubation croup and obstructive sleep apnea. Extubating the infant or child with a difficult airway should be orchestrated as carefully as intubating the infant or child with a difficult airway.