AANA journal
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Review Comparative Study
Epidural analgesia using loss of resistance with air versus saline: does it make a difference? Should we reevaluate our practice?
The choice of using air or saline in epidural syringes during the loss-of-resistance technique, for identifying the epidural space, has been based largely on personal preference of the anesthesia provider. A survey of practice in the United Kingdom, thought to be similar to practice in the United States, revealed that the majority of anesthesia providers use air. Case reports have appeared in the literature suggesting that air may be harmful to patients or, at the very least, impede the onset and quality of epidural analgesia. ⋯ Current anesthesia literature suggests using saline with an air bubble in the loss-of-resistance syringe. Many anesthesia training programs continue to teach the use of air, saline, and saline with an air bubble. Further studies may help to determine whether there is a scientific or safety basis for using air vs saline.
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Comparative Study
A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement.
Cuffed endotracheal tubes are one aspect of airway management designed to ensure safety, yet patients can be at risk for injury from underinflated and overinflated endotracheal cuffs. Tracheal pressures exceeding approximately 48 cm H2O impede capillary blood flow, potentially causing tracheal damage, and pressures below approximately 18 mm Hg may increase the risk of aspiration. There is no standard identified in the literature describing the method of cuff inflation, and nurse anesthetists use various cuff inflation techniques. ⋯ Analysis revealed that fewer than one third of the anesthesia providers inflated the cuff within an ideal range. No differences were found between level of anesthesia provider and cuff inflation pressures. We conclude that estimation techniques for cuff inflation are inadequate and suggest that direct measurements be used.
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General anesthesia aims to eliminate patients' awareness of excruciating pain during surgery. Nevertheless, rare occurrences of patient awareness continue because the problem is not yet completely preventable. One study puts the incidence of awareness at 0.18% for patients receiving muscle relaxants and at 0.10% for patients not given relaxant drugs. ⋯ Several depth-of-anesthesia monitors are available, but there is no ideal monitor that is 100% reliable. This review provides an overview of literature that reports findings associated with the monitoring and occurrence of intraoperative awareness. These studies indicate assessment methods that can be trusted when we provide general anesthesia and what measures can be taken to prevent recall by patients under general anesthesia.
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In the United States today, as many as one third of the population suffers from chronic pain conditions. These syndromes cost an estimated $80 billion and are a major source of burden to the healthcare system as well as to the suffering patients. According to a study by Harvard Medical School in 1997, visits to alternative medicine providers had reached 629 million, mostly for these pain conditions. ⋯ Many now believe that acupuncture should be considered a valuable asset in the specialty of pain, and that it can be of value in comprehensive pain clinics as well as physical therapy practice. Acupuncture is certainly not a cure-all; however, researchers and experienced clinicians both attest to its benefits. This article is a review of the literature with regard to acupuncture as a modality for pain management.
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Uterine rupture is an unexpected, relatively uncommon occurrence in the general obstetric population, but it is a potentially devastating complication. Uterine rupture of the unscarred uterus is extremely rare. Awareness of the risk factors as well as the signs and symptoms of uterine rupture are essential for an early diagnosis and prompt treatment. ⋯ An hour after delivery the patient began complaining of syncope; at this time bleeding was greater than expected and the obstetrician decided a dilatation and curettage for retained placenta was necessary. A dilatation and curettage was negative, and an ultrasound of the abdomen revealed the presence of significant blood clots, laparotomy was performed, and uterine rupture was identified. The patient developed disseminated intravascular coagulation, uterine bleeding continued, and the patient ultimately required a hysterectomy.