AANA journal
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Craniotomies are a common neurological intervention for intracranial tumor resections. Anesthesia techniques allow surgeons to aggressively and optimally resect neoplastic tissue while sparing normal cerebral tissue. Awake craniotomies are surgical techniques that enable surgeons to avoid damaging normal cerebral regions and allow real-time patient feedback. ⋯ Preoperative evaluation, regional anesthesia, general anesthesia, and monitored anesthesia are necessary to achieve a successful surgical intervention with awake craniotomy. As awake craniotomy gains more popularity, dependable anesthesia techniques remain critical. A discussion follows of the role of anesthesia providers in awake craniotomy during the entire perioperative continuum.
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We studied the current literature on human patient simulation for preparing anesthesia and other healthcare providers for advanced airway management. A systematic review was conducted of articles published between 1990 and 2009 on advanced airway management for patients undergoing anesthesia and patients who are not. The search used 4 electronic databases: Cumulative Index to Nursing & Allied Health Literature, MEDLINE, PsycINFO, and Web of Science. ⋯ Those studies included analyses of different types of training and the perceived value of simulated training, and evaluations of equipment. Few studies have analyzed the effects of this modality on trainer skills and patient safety. There is a clear need for well-designed studies to examine these effects.
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Case Reports
Selective bilateral bronchial intubation for large, acquired tracheoesophageal fistula.
The anesthetic management of patients undergoing tracheoesophageal fistula repair often involves lung separation, usually selective bronchial intubation with a double-lumen endotracheal tube. However, in patients with airway fistulas arising below the tracheal lumen, selective lung ventilation and separation may require unusual methods of airway management. ⋯ While lung separation was achieved, contrary to previous reports, the Mallinckrodt's larger and more tapered cuff made positioning in the left main bronchus an ongoing issue that required the use of a conventional endotracheal tube and, eventually, intubation of the bronchus from the surgical field. Future cases involving complex airway fistulas should consider endotracheal tube limitations and other methods of providing ventilation such as high-frequency jet ventilation or cardiopulmonary bypass.
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Case Reports
Anesthetic management for implantation of a treatment device: the Rheos Baroreflex Hypertensive Therapy System.
Resistant hypertension is a prevalent dilemma. Despite all available antihypertensive medications and multiple strategies such as healthier diets and exercise programs, many patients are still unable to maintain or reach a therapeutic goal for systolic blood pressure. Because of this major health concern, CVRx, Inc has developed a treatment involving baroreflex activation therapy (Rheos Baroreflex Hypertension Therapy System) to treat patients with uncontrolled high blood pressure. ⋯ This case report describes a 45-year-old African American woman with a history of hypertension who was receiving multiple antihypertensive medications and, thus, was a qualified candidate for implantation of this device. The goal of anesthetic management during implantation of this hypertension therapy system is to preserve the carotid sinus baroreceptor sensitivity by avoiding administering anesthetic agents that inhibit the baroreceptor reflex during electrode placement and the testing period. Because of the restriction of some of the anesthetic agents that an anesthesia provider can use, this procedure poses major challenges to the anesthesia provider in planning for anesthesia care and managing risks to the patient.
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Systemic blood pressure is regulated by 3 mechanisms: the sympathetic nervous system, the renin-angiotensin system, and the arginine-vasopressin system. The use of angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors has become prevalent in the medical treatment of hypertension. ⋯ This article describes the case of a 67-year-old man undergoing surgery for a spinal exploration who had hypotension following induction that was refractory to fluid administration and agents with mixed alpha-beta agonistic activity but responded to a vasopressin and phenylephrine infusion. Following the case study is a discussion of the impact that angiotensin II inhibitors may have on a patient undergoing general anesthesia and the role of vasopressin in reversing catecholamine-resistant hypotension.