AANA journal
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Adult caudal blockade has fallen from favor in the anesthesia community. The majority of anesthesia providers now use lumbar epidurals and spinals for surgeries that can be done with caudals. Many claim the procedure is difficult to perform and the outcome of the block is unpredictable. Caudal anesthesia has distinct advantages over lumbar epidurals and spinals and can be done with confidence by anesthetists who are willing to learn the anatomy, basic skills, and limitations entailed in this lost technique.
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Airway catastrophes have been identified as the leading cause of injury and death during anesthesia. Proper management of a patient with a technically difficult airway commences with problem recognition. Physical limitations to mask ventilation and endotracheal intubation may be accurately identified by thorough observation. ⋯ Prudent options may include awakening the patient, proceeding with mask ventilation, or performing semi-elective tracheostomy. Emergency airway access may be achieved with a tracheoesophageal airway, esophageal tracheal combitube, laryngeal mask airway, digital intubation, or obtained surgically by transtracheal jet ventilation or tracheostomy. Reduction of airway-related morbidity and mortality is best achieved with an understanding of airway anatomy, common causes and prompt recognition of compromise, and alternative techniques of establishing patency and ventilation.
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Case Reports
A case report: the use of ketamine and midazolam intravenous sedation for a child undergoing radiotherapy.
The combination of ketamine hydrochloride and midazolam was used to successfully provide intravenous sedation for a child requiring daily radiation treatments. During the radiation therapy treatments, the anesthesia provider was not in direct contact with the patient. Traditional monitoring was complemented by the addition of closed-circuit television monitoring. The drug combination provided consistent cardiac and respiratory stability, as well as patient immobility, for each radiation treatment.
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Three methods of warming intravenous (IV) fluids were examined. An in-line blood warmer was generally ineffective at flow rates of < 250 mL/hr but did produce temperatures of 30 to 31 degrees C at the catheter when the infusion rate was 500 to 1,000 mL/hr and the tubing was insulated. An in-line hot water bath produced temperatures of > or = 30 degrees C at flow rates of 200 to 1,000 mL/hr with uninsulated tubing. ⋯ Warming at rates of 200 to 1,000 mL/hr is most effective with an in-line hot water bath. Warming at low infusion rates is best accomplished with a K-Thermia pad. The use of in-line blood warmers for routine fluid warming is ineffective.
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Warming of intravenous fluids can decrease the incidence of hypothermia in surgical patients. A quasi-experimental research design was used to compare the delivered temperature of fluids using a conventional blood warmer and the Thermal Jacket, an insulation device designed for intravenous fluid bags. Fluids were divided into one control and three experimental groups. ⋯ Analysis of variance showed a highly significant difference between the delivered temperatures using the various temperature maintenance devices, as well as varying flow rates. The Thermal Jacket, used with prewarmed intravenous fluids, was as effective as the conventional method of delivering warmed fluids. Also, within the range of flow rates studied, faster flow rates tended to yield higher delivered temperatures.