AANA journal
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Peripheral nerve blocks are common and effective means for anesthesia for limb surgery. The evaluation of the success of a peripheral blockade is based on the loss of sensation, with no objective means of detecting a successful block. The autonomic innervation to the upper extremity, which controls both the vascular tone and the activity of sweat glands, is supplied by nerve fibers accompanying the somatic nerve fibers. ⋯ The electrical resistance of the skin on the palmar aspect of the forearm was continuously recorded on the block arm and on the contralateral arm using a commercial skin resistance monitor. No statistically significant change in the electrical resistance of the skin was observed during 20 minutes after placement of the block. These results strongly suggest that the electrical resistance of the skin cannot be used to predict a successful infraclavicular block.
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Placement of an epidural catheter in parturients can be challenging because the anatomic changes of pregnancy may make it difficult to palpate an ideal insertion point or detect loss of resistance. Preprocedural ultrasonography (U/S-P) is reported to facilitate placement of epidural catheters in parturients. ⋯ The purposes of this course are to describe the technique, systematically review the literature, and discuss techniques for integrating U/S-P into practice. It provides evidence demonstrating that U/S-P is a useful adjunct for placement of epidural catheters in obstetrical patients, especially patients with presumed "difficult backs" or obesity.
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Clinical Trial
Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.
This prospective, case-controlled observational study assessed whether an evidence-based extubation checklist would increase anesthesia providers' documentation of standardized extubation criteria and reduce the occurrence of preventable extubation failures in the early postoperative period. The sample consisted of 622 ASA Physical Status I to IV patients, aged 10 to 100 years but primarily adults, who underwent elective and emergency surgeries at a university-based adult trauma teaching hospital. Before the study, all anesthesia and postanesthesia care unit staff received an in-service on adherence to an evidence-based extubation checklist, followed by implementation of the checklist for 12 weeks. ⋯ Following use of the extubation checklist, documentation of patient readiness for extubation increased from 54% to 92.5%, and extubation failures decreased from 2.5 per month to 7.2 per month. This study confirmed that extubation failure occurred less frequently when the extubation checklist was used (P = .001, Fisher exact test). Study results indicate that an extubation checklist may positively influence provider documentation of evidence-based criteria for extubation and can reduce the occurrence of preventable extubation failures.
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Case Reports
Utilization of a massive transfusion protocol during liver lobe resection: a case report.
The literature shows substantial data that acute coagulopathy and hemorrhage without rigorous resuscitative efforts has a high morbidity and mortality. The utilization of protocols for a massive transfusion and resuscitation can lead to improved outcomes in morbidity and mortality. ⋯ Research and evidence from the armed services has shown remarkable improvements in morbidity and mortality when a massive transfusion protocol is implemented in the care of traumatically injured soldiers. The use and continued review of these military data appear to have a substantial impact on how the civilian healthcare system addresses massive transfusion and resuscitation in the critically injured and hemorrhagic patient.
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Protamine sulfate is used during coronary artery bypass graft surgery to reverse the anticoagulating effects of heparin. Vasoplegic syndrome is a state of endothelial dysregulation that produces profound vasodilatation that is refractory to vasopressors. This syndrome leads to systemic hypoperfusion and may progress to death. ⋯ A dramatic increase in blood pressure resulted almost immediately after administration of methylene blue. This patient had no prior risk factors for a protamine reaction other than her current cardiac surgery. A review of the pathophysiologic characteristics associated with vasoplegia and the pharmacodynamics of methylene blue will potentially enable anesthesia providers to utilize this lifesaving drug when needed.