AANA journal
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Despite compelling evidence for the safety and efficacy of intrathecal hydromorphone, the use of this opioid intrathecally for the pain management of patients undergoing cesarean delivery has not been widely accepted. The purpose of this retrospective study was to compare the reported efficacy and safety of pain management in women who received intrathecal hydromorphone (100 microg) vs in women who received intrathecal fentanyl (25 microg) or a local anesthetic for their cesarean delivery. The author hypothesized that intrathecal hydromorphone because of its known pharmacodynamics would provide better postoperative analgesia within the first 24 hours after cesarean delivery. ⋯ Traditionally, intrathecal morphine was the opioid of choice for prolonged pain management during cesarean deliveries in which spinal anesthesia was selected. However, intrathecal hydromorphone was shown to be an effective and possibly even better substitute. Further research on intrathecal hydromorphone is needed.
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Cocaine has been associated with acute hemodynamic changes, causing anesthesia providers to be concerned about adverse hemodynamic events during general anesthesia. We sought to determine if there were differences in the prevalence of adverse hemodynamic events, and if hemodynamic instability could be predicted in cocaine-positive patients undergoing general anesthesia for elective surgery. A retrospective cohort study was conducted in 300 (150 cocaine-positive, 150 cocaine-negative) consecutive adults with similar general anesthesia plans who were hemodynamically normal at baseline. ⋯ Slightly more than 50% of subjects were female, but cocaine-positive subjects were significantly more likely to be male (chi2 = 5.9; P = .02). Baseline systolic pressure (P = .001; mean difference, 6.5 mm Hg; 95% confidence interval [CI], 2.7-70.2), mean arterial pressure (P = .04; mean difference, 2.9 mm Hg; 95% CI, 1.0-5.7), and heart rate (P = .02; mean difference, 3.3/min; 95% CI, 0.46-6.2) were significantly higher, but not clinically important in the cocaine-positive cohort. Our study demonstrates that use of drug screen results alone is insufficient to predict the safe administration of general anesthesia in patients undergoing elective surgeries.
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Placement of an epidural catheter in parturients can be challenging because the anatomic changes of pregnancy may make it difficult to palpate an ideal insertion point or detect loss of resistance. Preprocedural ultrasonography (U/S-P) is reported to facilitate placement of epidural catheters in parturients. ⋯ The purposes of this course are to describe the technique, systematically review the literature, and discuss techniques for integrating U/S-P into practice. It provides evidence demonstrating that U/S-P is a useful adjunct for placement of epidural catheters in obstetrical patients, especially patients with presumed "difficult backs" or obesity.
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Case Reports
Utilization of a massive transfusion protocol during liver lobe resection: a case report.
The literature shows substantial data that acute coagulopathy and hemorrhage without rigorous resuscitative efforts has a high morbidity and mortality. The utilization of protocols for a massive transfusion and resuscitation can lead to improved outcomes in morbidity and mortality. ⋯ Research and evidence from the armed services has shown remarkable improvements in morbidity and mortality when a massive transfusion protocol is implemented in the care of traumatically injured soldiers. The use and continued review of these military data appear to have a substantial impact on how the civilian healthcare system addresses massive transfusion and resuscitation in the critically injured and hemorrhagic patient.
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Protamine sulfate is used during coronary artery bypass graft surgery to reverse the anticoagulating effects of heparin. Vasoplegic syndrome is a state of endothelial dysregulation that produces profound vasodilatation that is refractory to vasopressors. This syndrome leads to systemic hypoperfusion and may progress to death. ⋯ A dramatic increase in blood pressure resulted almost immediately after administration of methylene blue. This patient had no prior risk factors for a protamine reaction other than her current cardiac surgery. A review of the pathophysiologic characteristics associated with vasoplegia and the pharmacodynamics of methylene blue will potentially enable anesthesia providers to utilize this lifesaving drug when needed.