Richard P Gerraty MD, FRACP

• Neurologist, The Alfred Hospital, Melbourne, Vic
• Associate Professor, Department of Medicine, Monash University

Each fiber is 8 to 12 microns in diameter and is coated with a secondary glass layer termed cladding birth control 21 day pack purchase yasmin 3.03 mg free shipping. Broken fibers birth control success rate order generic yasmin on-line, which can easily occur with bending of the insertion cord birth control estradiol purchase yasmin australia, entrapping of the cord in other equipment birth control for women over age 35 purchase generic yasmin line, or dropping the fiberoptic bronchoscope birth control effectiveness buy cheap yasmin, are readily apparent as missing pixels in the image birth control for women 7 feet generic yasmin 3.03 mg fast delivery. These are typically just a nuisance until the number of broken fibers interferes with the visual field. A single-use version of this technology is available (aScope 3, Ambu, Ballerup, Denmark;. Along with imaging elements, the insertion cord contains an accessory 1974 lumen or "working channel": a lumen, up to 2 mm in diameter, which travels from the distal tip to the handle. In general, flexible intubation scopes that are less than 2 mm in external diameter. Table 28-19 Contraindications to Flexible Scope Intubation the distal end of the insertion cord is hinged for movement. Two wires, traveling from the control lever in the handle down the length of the insertion cord, control the movement of the distal tip in the sagittal plane. Coronal plane movement is accomplished by a combined use of the control lever and rotation of the entire flexible intubation scope (from handle to distal end). It is key to keep the insertion cord completely straight as this maximizes rotational control by ensuring that rotation of the hand piece translates to identical rotation of the distal tip. In the fiberoptic devices, illumination of the objective is provided by one or two noncoherent bundles of glass fibers that transmit light from the handle to the distal tip. The light is provided either by a cord that emerges from the handle and is inserted into an endoscopic light source or may be provided by a portable battery-operated light source on the handle. Apart from the delicate optics, there are cameras, recorders, light sources, and a variety of disposable adjuncts that are typically required. Dedicated wheeled carts, designed to carry equipment in a functional arrangement, are often utilized. Use of the Flexible Intubation Scope the flexible intubation scope is held with the thumb over the control lever and the index finger poised over the working channel valve. The contralateral hand is used to steady and hold the insertion cord at the level of the patient. An experienced endoscopist will recognize that the fine control required for steadying the bronchoscope while making minute directional adjustments and advancing it through the airway is where the art of endoscopy lies. This is most thoroughly described with flexible scope-aided intubation, for which it occurs in 20% to 30% of attempts. The nasal tube is softened in warm saline or water199 and well lubricated prior to insertion. While mandibular advancement and/or tongue extraction typically suffice, a variety of oral airways designed to facilitate flexible scope orotracheal intubation are commercially available. These devices function to provide a clear visual path from the oral aperture to the hypopharynx, keep the bronchoscope and tracheal tube midline, prevent the patient from biting the insertion cord, and provide a clear airway for spontaneous or mask ventilation. The flat lingual surface of the airway affords lateral and 1978 rotational stability. Both the Williams and the Berman airways were designed for blind orotracheal intubation. These airways have a smaller profile than the Ovassapian airway, but tend to have less rotational stability. The Berman airway addresses this problem with a split along the length of one side. After successful navigation past the tongue (whether facilitated by tongue extraction, mandibular advancement, or an intubating oral airway), the endoscopist visualizes the vocal folds. If glottic closure, gag, or coughing occurs, the operator can choose to apply local anesthetic through the working channel, administer more intravenous sedation, withdraw the scope and reinforce airway analgesia, or advance the scope into the larynx without further preparation. In the elective scenario, there is likely to be time for additional airway preparation, whereas in the face of impending respiratory arrest, patient discomfort may need to be tolerated. Once the larynx is entered, the flexible scope is advanced until the carina is visualized. Simply having the flexible scope enter the trachea does not guarantee that the intubation will be successful; hang-up and accidental scope withdrawal (via coughing or inattention) may still occur. Therefore, a patient with a critical airway should not be induced with a general anesthetic until intratracheal tube placement is confirmed. The primary literature contains a number of variations and adjuncts to flexible scope-aided intubation. Table 28-21, which is not meant to be exhaustive, lists several of these techniques. As cricoid pressure is held (Sellick maneuver), a hypnotic and succinylcholine are administered. Macintosh 4 and Miller 3 blades are utilized without improvement of the glottic view. Oxygen saturation has fallen from 100% to 92% and facemask ventilation is initiated with maintenance of cricoid pressure. Placement of an oral airway, chin and jaw lift, two-person ventilation, and reduction in the degree of cricoid pressure do not result in adequate mask ventilation. Case 4: Deviation from the Difficult Airway Algorithm Thirteen hours after admission to the intensive care unit, a 76-year-old woman with head, neck, and facial trauma from a motor vehicle accident is noted to have progressive decline in her level of consciousness and respiratory effort. On examination, there appears to be an adequate interincisor gap and thyromental distance, but the oropharyngeal view and cervical range of motion cannot be evaluated. Because of the inability to evaluate her airway fully with respect to ease of intubation, an awake technique is chosen. Oropharyngeal blood from continued epistaxis suggests that adequate drying and analgesia of the airway may be difficult and that the use of a flexible intubation device may not be prudent. Blind nasal intubation is contraindicated based on the obvious facial trauma and the risk of cribriform plate disruption. Neither an esophageal tube nor equipment for retrograde intubation is readily available. Due to significant patient resistance (head and neck movement and biting of the laryngoscope), tracheal intubation is not achieved. Muscle Relaxants and Direct Laryngoscopy In the case described, the use of muscle relaxants significantly improved laryngeal visualization. Muscle relaxation improves laryngoscopic view by facilitating temporomandibular joint relaxation, relaxation of the supraglottic larynx, and anterior movement of the epiglottis. Neuromuscular blockade tends to facilitate facemask ventilation and is often utilized in cases in which facemask ventilation is unexpectedly difficult. The classic teaching of withholding muscle relaxants until facemask ventilation has been demonstrated is rapidly being abandoned. Knowing that failure to intubate would likely result in loss of the airway, the clinical team was wisely prepared for cricothyrotomy. As stated earlier, adaptability in rapidly changing clinical scenarios is critical to the success of airway management. Other Devices An ever-increasing number of airway management devices are commercially available. Although encyclopedic coverage of these tools is beyond the scope of this chapter, a review of the more established equipment follows. When properly inflated, the cuffs prevent esophageal and oral leakage of gasses, making the larynx the route of least resistance for inspired gasses. Airway Bougie Airway bougies are semimalleable stylets that may be blindly manipulated through the glottis when a poor laryngeal view is obtained (CormackLehane grade 3 or 4). This introducer (also known as the gum elastic bougie) can be manipulated under the epiglottis, its angled segment directed anteriorly toward the larynx. The 1983 lumen allows for the insufflation of oxygen, detection of carbon dioxide, and use of a self-inflating bulb to detect inadvertent esophageal placement. An optional "stiffening" stylet can be placed through the lumen to increase device rigidity. Though the noninvasive tools of the modern airway armamentarium can manage most situations, the clinician must be familiar with these alternative techniques of intubation, oxygenation, and ventilation for both elective and emergency airway access. This text will focus on percutaneous techniques, as surgical tracheostomy and cricothyrotomy are beyond the scope of this chapter. This wire is blindly passed in the cephalad direction into the hypopharynx, pharynx, and out of the mouth or nose and then used as an intubating conduit. Although cricothyrotomy is the procedure of choice in an emergency situation, it may also be of use in elective situations when there is limited access to the trachea. Cricothyrotomy is contraindicated in children younger than 6 years of age and in patients with laryngeal fractures. Otolaryngologists and other surgical services prefer transtracheal airway access caudad to the cricoid cartilage 1985 whenever feasible due to the high incidence of long-term complications after surgical cricothyrotomy. As an example, the success rate of cannula cricothyrotomy performed by an anesthesia provider is roughly 50%,1 while the success rate of an emergency surgical airway performed by a surgeon or trained prehospital provider is 90% to 100%. A large-bore translaryngeal catheter (14 gauge or larger) attached to a 5- to 10-mL empty or fluid-filled (saline or local anesthetic) syringe is used. From the moment of skin puncture, there should be constant aspiration on the syringe plunger. Free aspiration of air confirms entrance into the trachea (aircontrast technique) but does not indicate the direction that the catheter travels in the larynx; this is important, as cephalad advancement will not provide adequate oxygenation. Once the catheter has been successfully placed, a high-pressure oxygen source should be attached. A 50-psi oxygen source with a metered and adjustable hand-controlled valve and a Luer-lock connector. Insufflation and expiration ratios, as well as driving pressure, are adjusted to provide visible chest excursion and recoil. If a 14-gauge catheter has been placed, this system will deliver a tidal volume of 400 to 700 mL. Low-pressure systems cannot provide enough flow to expand the chest adequately for oxygenation and ventilation. These systems are capable of delivering a constant flow of 15 L/min and have been shown to be effective for resuscitation. For example, using a standard three-way stopcock as a flow diverter is potentially hazardous, as forward flow (inspiration) is never fully stopped. The Enk flow modulator has been used successfully in models of near and complete upper airway obstruction. The clear benefit is the avoidance of air trapping in the lungs, especially when the upper airway is completely obstructed. While both devices facilitated reoxygenation, the Ventrain was associated with superior minute ventilation (4. The Ventrain has also proven effective in both elective and emergent human airway management. Specialized percutaneous cricothyrotomy systems have been developed to improve the ease of transtracheal ventilation. These devices generally provide large-bore access adequate for oxygenation and ventilation with low-pressure systems. Preparation and positioning of the patient are the same as with needle cricothyrotomy. After air is aspirated, the catheter is advanced into the trachea as described earlier. The catheter is removed and the large-bore tracheal cannula, fitted internally with a curved dilator, is threaded onto the wire. Significant resistance on advancement typically indicates that the skin incision needs to be extended. Conclusions Apart from monitoring, management of the "routine" airway is the most common task of the anesthesia provider. Even during the administration of regional anesthesia, the airway must be monitored and possibly supported. The consequences of a lost airway are so devastating that the clinician can never afford a lackadaisical approach. Judgment, experience, the clinical situation, and available resources all affect the appropriateness of the chosen pathway through, or divergence from, the algorithm. Although an increasingly vast array of devices exists, the clinician does not need to be expert in all the equipment and techniques, and no single device can be considered superior to another when viewed in isolation. Rather, a broad range of approaches should be mastered so that the failure of one does not preclude safe airway management and emergency rescue. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. The Airway Approach Algorithm: a decision tree for organizing preoperative airway information.

Despite achieving a negative fluid balance birth control for 5 years in the arm best purchase yasmin, the conservative strategy group had no greater incidence of acute renal failure birth control list quality yasmin 3.03mg. Colloids birth control pills night sweats yasmin 3.03 mg with amex, Crystalloids birth control for women 9mm safe 3.03 mg yasmin, and Hypertonic Solutions Physiology and Pharmacology Osmotically active particles attract water across semipermeable membranes until equilibrium is attained birth control pills canada buy yasmin 3.03 mg low cost. Sugars birth control pills yarina buy yasmin master card, alcohols, and radiographic dyes increase measured osmolality, generating an increased "osmolal gap" between the measured and calculated values. The term tonicity is also used colloquially to compare the osmotic pressure of a parenteral solution to that of plasma. The reflection coefficient () describes the permeability of capillary membranes to individual solutes, with 0 representing free permeability and 1 representing complete impermeability. The filtration rate of fluid from the capillaries into the interstitial space is the net result of a combination of forces, including the gradient from intravascular to interstitial colloid osmotic pressures and the hydrostatic gradient between intravascular and interstitial pressures. The net fluid filtration at any point within a systemic or pulmonary capillary is approximated by Starling law of capillary filtration, as expressed in the equation: where Q = fluid filtration, k = capillary filtration coefficient (conductivity of water), A = area of the capillary membrane, Pc = capillary hydrostatic pressure, Pi = interstitial hydrostatic pressure, = the reflection coefficient for albumin, i = interstitial colloid osmotic pressure, and c = capillary colloid osmotic pressure. However, it is important to note that the Starling law does not account for the influence on fluid filtration of the capillary glycocalyx, which is strongly influenced by disease processes and fluid administration. Pc, the most powerful factor promoting fluid filtration, is determined by capillary flow, arterial resistance, venous resistance, and venous pressure. If capillary filtration increases, the rates of water and sodium filtration usually exceed protein filtration, resulting in preservation of c, dilution of i, and preservation of the oncotic pressure gradient, the most powerful factor opposing fluid filtration. However, because of the influence of the glycocalyx, theoretical rates of fluid filtration usually substantially exceed actual filtration rates, a phenomenon termed the "low lymph flow paradox. However, exhaustive research has failed to establish the superiority of either colloid-containing or crystalloid-containing fluids for either intraoperative or postoperative use. Despite the lack of conclusive evidence of efficacy, albumin has been used in critically ill patients for decades. In burn patients who received albumin, mortality and the incidence of abdominal compartment syndrome were reduced. Cirrhotic patients may represent a specific subset of patients in whom albumin infusion could be beneficial. In patients with decompensated cirrhosis, infusion of albumin reduced prostaglandin E2 and improved macrophage function. Resuscitation with only 50 mL/kg of isotonic lactated Ringer solution did not increase brain water, but also failed to restore blood volume. Hypertonic, hypernatremic solutions, with or without added colloid, appear to fulfill some of these criteria (Table 16-12). Hypertonic solutions exert favorable effects on cerebral hemodynamics, in part because of the reciprocal relationship between plasma osmolality and brain water. Despite theoretical considerations favoring the use of hypertonic saline in resuscitation of patients with traumatic brain injury, a subsequent randomized trial failed to demonstrate an improvement in outcome. Pending further preclinical work, the theoretical advantages of such fluids appear most attractive in the acute resuscitation of hypovolemic patients who have decreased intracranial compliance. Although this goal is conventionally accomplished with mannitol, some clinicians prefer hypertonic 1027 saline solutions. However, infusion of hypertonic saline increases intravascular volume, while diuresis secondary to mannitol decreases intravascular volume. Table 16-12 Hypertonic Resuscitation Fluids: Advantages and Disadvantages Fluid Status: Assessment and Monitoring For most surgical patients, conventional clinical assessment of the adequacy of intravascular volume is appropriate. Assessment of hypovolemia is mainly based in physical signs that include oliguria, supine hypotension, and a positive tilt test. In general, oliguria implies hypovolemia, keeping in mind that hypovolemic patients can have adequate urinary output and that urinary output can be misleadingly high. Supine hypotension suggests a blood volume deficit greater than 30%, although in elderly or chronic hypertensive patients, an arterial blood pressure within the normal range could represent relative hypotension. A positive tilt test, defined as an increase in heart rate of at least 20 beats per minute and a decrease in systolic blood pressure of 20 mmHg or more when the subject assumes the upright position, can be falsely negative. In contrast, orthostasis may occur in 20% to 30% of elderly patients despite normal blood volume. In volunteers, withdrawal of 500 mL of blood84 was associated with a greater increase in heart rate on standing than before blood withdrawal, but with no significant difference in the response of blood pressure or cardiac index. In acute hemorrhage, hematocrit decreases slowly as fluid shifts from the interstitial to the intravascular space and more rapidly during administration of fluids. The sensitivities and specificities of measurements of blood and urinary variables to hypovolemia are poor. In prerenal oliguria, enhanced sodium reabsorption should reduce urinary [Na+] to 20 mEq/L or less and enhanced water reabsorption should increase urinary concentration. Intraoperative Clinical Assessment Both surgeons and anesthesiologists tend to underestimate blood loss, based on assessment of blood on surgical gauze pads, pooled on the floor, and accumulated in the surgical field and suction containers. Assessment of the adequacy of intraoperative fluid resuscitation integrates multiple clinical variables, including heart rate, blood pressure, urinary output, arterial oxygenation, and pH. In patients receiving potent inhalational agents, maintenance of blood pressure within the normal range implies adequate intravascular volume. When measured, a central venous pressure of 6 to 12 mmHg suggests adequate blood volume. Tachycardia is an insensitive and 1029 nonspecific indicator of hypovolemia that is also altered by anesthetic drugs. In severe hypovolemia, the accuracy of indirect measurements of blood pressure diminishes. Under those circumstances, direct arterial pressure measurements are more accurate than indirect techniques. Therefore, in the absence of glycosuria or diuretic administration, a urinary output of 0. Mixed venous hemoglobin desaturation, a specific indicator of poor systemic perfusion, reflects average perfusion in multiple organs and cannot supplant regional monitors such as urinary output. Assessment increasingly depends on dynamic physiologic variables rather than static variables such as central venous pressure. Esophageal Doppler assessment of blood flow in the descending aorta is another promising technique in measuring adequacy of cardiac preload during high-risk surgical procedures. Using the esophageal Doppler to guide administration of colloid boluses, Venn et al. Of note, Horowitz and Kumar95 speculated that the infusion of colloid rather than the monitor-driven algorithm was responsible for the improved results. Large multicenter trials are needed in order to ascertain the benefits of the described novel techniques in perioperative outcomes of patients undergoing high-risk surgery. Postoperative cardiovascular complications occurred significantly more frequently in the group receiving fluids alone (13/25, 52%, vs. Another specific risk associated with use of fluids to achieve goal-oriented resuscitation is an increased incidence of abdominal compartment syndrome in trauma patients. Disorders of sodium concentration, that is, hyponatremia and hypernatremia, usually result from relative excesses or deficits, respectively, of water. Regulation of total body sodium and [Na+] is accomplished primarily by the endocrine and renal systems (Table 16-13). Therefore, primary hyperaldosteronism is associated with hypervolemia and with hypertension, but not with abnormal [Na+]. The most common clinical scenarios associated with hyponatremia include the postoperative state, acute intracranial disease, malignant disease, medications, and acute pulmonary disease. Recently, hyponatremia, as well as hypokalemia and hypophosphatemia, have been recognized as complications of immunologic treatment of cancers such as hepatocellular carcinoma and melanoma. Symptoms that can accompany severe hyponatremia ([Na+] < 120 mEq/L) include loss of appetite, nausea, vomiting, cramps, weakness, altered level of consciousness, coma, and seizures. Because the brain does not rapidly compensate for changes in osmolality,106 acute hyponatremia produces more severe symptoms than chronic hyponatremia. The symptoms of chronic hyponatremia probably relate to depletion of brain electrolytes. Once brain volume has compensated for hyponatremia, rapid increases in [Na+] may lead to abrupt brain dehydration. Hyponatremia with a normal or high serum osmolality results from the presence of a nonsodium solute, such as glucose or mannitol, which holds water within the extracellular space and results in dilutional hyponatremia. The presence of a nonsodium solute may be inferred if measured osmolality exceeds calculated osmolality by over 10 mOsm/kg. Hyposmolality is more important in generating symptoms than is hyponatremia per se. In contrast, as glycine or sorbitol is metabolized, hyposmolality will gradually develop, and cerebral edema may appear as a late complication. Hyponatremia with a normal or elevated serum osmolality also may accompany renal insufficiency. Calculation of effective osmolality (2[Na+] + glucose/18) excludes the contribution of urea to osmolality and demonstrates true hypotonicity. Hyponatremia with increased total body sodium is characteristic of edematous states, that is, congestive heart failure, cirrhosis, nephrosis, and renal failure. Aquaporin 2, the vasopressin-regulated water channel, is upregulated in experimental congestive heart failure109 and cirrhosis110 and decreased by chronic vasopressin stimulation. In patients with renal insufficiency, reduced urinary diluting capacity can lead to hyponatremia if excess free water is given. Thiazide diuretics, unlike loop diuretics, promote hypovolemic hyponatremia by interfering with urinary dilution in the distal tubule. In patients after subarachnoid hemorrhage, administration of hydrocortisone 1,200 mg/day prevented the cerebral salt-wasting syndrome. Although neurologic manifestations usually do not accompany mild postoperative hyponatremia, signs of hypervolemia are occasionally present. Women appear to be more vulnerable than men, and premenopausal women appear to be more vulnerable than postmenopausal women to brain damage secondary to postoperative hyponatremia. Urinary [Na+] is generally below 15 mEq/L in edematous states and volume depletion and above 20 mEq/L in hyponatremia secondary to renal salt wasting or renal failure with water retention. Treatment of edematous (hypervolemic) patients necessitates restriction of both sodium and water, usually accompanied by efforts to improve cardiac output and renal perfusion and to use diuretics to inhibit sodium reabsorption. In hypovolemic, hyponatremic patients, blood volume must be restored, usually by infusion of 0. During treatment of hyponatremia, increases in plasma [Na+] are determined both by the composition of the infused fluid and by the rate of renal free water excretion. Hypertonic (3%) saline is most clearly indicated in patients who have seizures or who acutely develop symptoms of water intoxication secondary to intravenous fluid administration. In such patients, acute hyponatremia is associated with severe brain swelling that can lead to herniation. Intravenous furosemide, combined with quantitative replacement of urinary sodium losses with 0. The rate of treatment of hyponatremia continues to generate controversy, extending from "too fast, too soon" to "too slow, too late. The symptoms of the osmotic demyelination syndrome vary from mild (transient behavioral disturbances or seizures) to severe (including pseudobulbar palsy and quadriparesis). The principal determinants of neurologic injury appear to be the severity and chronicity of hyponatremia and the rate of correction. The osmotic demyelination syndrome is more likely when hyponatremia has persisted for longer than 48 hours. Most patients in whom the osmotic demyelination syndrome is fatal have undergone correction of plasma [Na+] of more than 20 mEq/L/day. Other risk factors for the development of osmotic demyelination syndrome include alcoholism, poor nutritional status, liver disease, burns, and hypokalemia. Rapid increases in plasma sodium concentration, especially when those increases occur with overzealous correction of chronic hyponatremia, may cause the osmotic demyelination syndrome (also termed central pontine myelinolysis). Frequent determinations of [Na+] are important to prevent correction at a rate above 1 to 2 mEq/L in any 1 hour and above 8 mEq/L in 24 hours. Once plasma [Na+] exceeds 120 to 125 mEq/L, water restriction alone is usually sufficient to normalize [Na+]. As acute hyponatremia is corrected, central nervous system signs and symptoms usually improve within 24 hours, although 96 hours may be necessary for maximal recovery. For patients who require long-term pharmacologic therapy of hyponatremia, vasopressin receptor antagonists are the current most promising therapies. Once hyponatremia has improved, careful fluid restriction is necessary to avoid recurrence of hyponatremia. Hypernatremia Hypernatremia ([Na+] > 150 mEq/L) indicates an absolute or relative water deficit. Therefore, severe, persistent hypernatremia occurs only in patients who cannot respond to thirst by voluntary ingestion of fluid, that is, obtunded patients, anesthetized patients, and infants. Hypernatremia produces neurologic symptoms (including stupor, coma, and seizures), hypovolemia, renal insufficiency (occasionally progressing to renal failure), and decreased urinary concentrating ability. Geriatric patients are at increased risk of hypernatremia because of decreased renal concentrating ability and decreased thirst. Brain shrinkage secondary to rapidly developing hypernatremia may damage delicate cerebral vessels, leading to subdural hematoma, subcortical parenchymal hemorrhage, 1042 subarachnoid hemorrhage, and venous thrombosis. Polyuria may cause bladder distention, hydronephrosis, and permanent renal damage. Although the mortality of patients with hypernatremia is 40% to 55%, it is unclear whether hypernatremia contributes to mortality or is simply a marker of severe associated disease. Surprisingly, if plasma [Na+] is initially normal, moderate acute increases in plasma [Na+] do not appear to precipitate central pontine myelinolysis.

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