Best practice & research. Clinical anaesthesiology
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Despite the use of alternative training methods and efforts to structure training, it remains a challenge to ensure that every anaesthesia trainee gains sufficient experience in the use of core techniques of airway management. As less time is spent in the operating room during training, it becomes less likely that trainees will be exposed to an adequate number of challenging airway cases that enable them to practise advanced techniques of airway management under supervision. ⋯ Therefore, particularly in the light of increasing economic pressures, it is necessary to address the responsibilities of everyone involved in the training process. Here, we critically review traditional and recent modalities of anaesthesia training, assess their value, and describe a multi-modal approach to airway management education.
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Fiberoptic intubation of the spontaneously breathing patient is the gold standard and technique of choice for the elective management of a difficult airway. In the hands of the properly trained and experienced user, it is also an excellent 'plan B' alternative when direct laryngoscopy unexpectedly fails. ⋯ Portable fiberscopes can be used in remote settings, increasing patient safety. This review discusses current fiberoptic intubation techniques and their applications in the management of both the anticipated and unanticipated difficult airway.
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Anaesthesiologists, paediatricians, paediatric intensivists and emergency physicians are routinely challenged with airway management in children and infants. There are important differences from adult airway management as a result of specific features of paediatric anatomy and physiology, which are more relevant the younger the child. In addition, a number of inherited and acquired pathological syndromes have significant impact on airway management in this age group. ⋯ Important new studies have gathered evidence about risks and benefits of certain confounding variables for airway problems and specific techniques for solving them. Airway-related morbidity and mortality in children and infants during the perioperative period are still high, and only a thorough risk determination prior to and continuous attention during the procedure can reduce these risks. Appropriate preparation of the available equipment and frequent training in management algorithms for all personnel involved appear to be very important.
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Even nowadays every third or fourth patient suffers from postoperative nausea and vomiting (PONV) after general anaesthesia with volatile anaesthetics. There is now strong evidence that volatile anaesthetics are emetogenic and that there are no meaningful differences between halothane, enflurane, isoflurane, sevoflurane, and desflurane in this respect. However, when propofol is substituted for volatile anaesthetics the risk for PONV is reduced by only about one fifth, indicating that there are other even more important causes for PONV following general anaesthesia. ⋯ This means that any anti-emetic prophylaxis for PONV induced by volatile anaesthetics is equally effective. Of course, the most logical approach for prevention would be the omission of volatile anaesthetics and nitrous oxide using a total intravenous anaesthesia with propofol. However, since volatile anaesthetics are probably not the most important risk factors, it might be even better--if appropriate--to avoid general anaesthesia by using a regional, opioid-free anaesthesia if PONV is a serious problem.
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Best Pract Res Clin Anaesthesiol · Sep 2005
Review Historical ArticleInhaled anesthetics: an historical overview.
Inhalational agents have played a pivotal role in anesthesia history. The first publicly demonstrated anesthetic of the modern era, diethyl ether, was an inhalational anesthetic. The attributes of a good agent, ability to rapidly induce anesthesia, with limited side effects has led research efforts for over a hundred and fifty years. ⋯ Rapid emergence, with limited nausea and vomiting continue to drive discovery efforts, yet the 'modern' agents continue to improve upon those in the past. The future holds promise, but perhaps the most interesting contrast over time is the ability to rapidly introduce new agents into practice. From James Young Simpson's dinner table one evening to the operating suite the next day, modern agents take decades from first synthesis to clinical introduction.