Canadian journal of anaesthesia = Journal canadien d'anesthésie
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The practice of regional anesthesia has been revitalized of late with the popularization of ultrasound-guided techniques. Advocates must be vigilant for the effects of unintentionally high blood levels of local anesthetic. Systemic local anesthetic toxicity, though rare, is a potentially devastating occurrence. This narrative review summarizes the effects of local anesthetic toxicity. We highlight how these toxic effects have motivated the search for a safe and long-acting local anesthetic. We outline current prevention and treatment options and appraise an emerging therapy in light of unfolding evidence. ⋯ Vigilance during the performance of regional anesthesia and immediate intervention at the earliest sign of toxicity improve the chances of successful treatment.
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In conventional practice of epidural needle placement, determining the interspinous level and choosing the puncture site are based on palpation of anatomical landmarks, which can be difficult with some subjects. Thereafter, the correct passage of the needle towards the epidural space is a blind "feel as you go" method. An aim-and-insert single-operator ultrasound-guided epidural needle placement is described and demonstrated. ⋯ This small study demonstrates the feasibility of the ultrasound-guidance technique. Areas for further development are identified for both ultrasound software and physical design.
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Comparative Study
Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty.
To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood. ⋯ A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.
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Case Reports
Accidental fracture of the tip of the Coopdech bronchial blocker during insertion for one lung ventilation.
The distal tip of a Coopdech bronchial blocker has a preformed angulation to aid placement in the desired bronchus. We report two cases wherein this design may have resulted in distal tip fracture due to entanglement at the level of the Murphy's eye of the endotracheal tube or at the carina. ⋯ The preformed tip of the Coopdech bronchial blocker can be damaged at the Murphy's eye of the endotracheal tube or at the carina. This can result in tip fracture, especially during insertion into the right main bronchus. Maneuvering the tip away from the Murphy's eye can circumvent this problem. Continuous bronchoscopic guidance should be used as recommended by the manufacturer.
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Rapid sequence induction (RSI) with cricoid pressure is suggested to decrease the risk of aspiration of gastric contents. However, the effectiveness of RSI has been questioned, and the technique may lead to airway and hemodynamic complications. The purpose of this study was to determine the frequency of RSI use in patients with acute appendicitis, the types of drugs administered, and the occurrence of any complications. ⋯ An RSI with opioid, induction agent, and succinylcholine is the technique of choice for appendectomies at our institution. The frequency of airway complications is too low to recommend a change in practice.