Articles: function.
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Anesthesia and analgesia · Nov 2014
Randomized Controlled Trial Comparative StudySurgical Space Conditions During Low-Pressure Laparoscopic Cholecystectomy with Deep Versus Moderate Neuromuscular Blockade: A Randomized Clinical Study.
Laparoscopic cholecystectomy performed during low intraabdominal pressure (<12 mm Hg) is associated with significantly less postoperative pain than standard pressure (≥12 mm Hg). The impact on surgical space conditions and safety of operating at lower pressures has not been adequately described, but deep neuromuscular blockade may be beneficial. We investigated if deep muscle relaxation would be associated with a higher proportion of procedures with "optimal" surgical space conditions compared with moderate relaxation during low-pressure (8 mm Hg) laparoscopic cholecystectomy. ⋯ Deep neuromuscular blockade was associated with surgical space conditions that were marginally better than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy.
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Propionic acidemia is a congenital disorder of metabolism where the enzyme propionyl-CoA carboxylase is nonfunctional, resulting in an accumulation of propionic acid in the blood. It is important to avoid excess protein intake and a catabolic state to prevent acidemia. Additionally, it may be wise to avoid anesthetic drugs metabolized by propionyl-CoA carboxylase because use of these drugs may lead to acidosis. We present a case of a parturient with propionic acidemia who presented for induction of labor.
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Shock is defined as a situation where oxygen transport and delivery is inadequate to meet oxygen demand. The patient in shock is evaluated through medical history, physical examination, and careful observation of the hemodynamic and respiratory monitors. The patient is initially managed with basic resuscitation measures, however bedside ultrasound should be performed if hemodynamic instability persists. We propose to use ultrasound of the inferior vena cava (IVC), and the concept of venous return, as the initial step in order to identify the mechanism of shock. Doppler examination of the hepatic venous flow can also be added. Further ultrasound examination of the patient's heart, thorax, and abdomen can then be performed in order to determine the etiology of shock. In patients with reduced mean systemic venous pressure, an examination of the patient's thoracic and abdominal cavities to detect free fluid, pneumonia, or empyema can be considered. In patients with increased right atrial pressure, transthoracic echocardiography will allow identification of left or right ventricular dysfunction. Finally, in the presence of increased resistance to venous return, thoracic examination for pneumothorax or cardiac tamponade and abdominal examination for signs of abdominal compartment syndrome or IVC occlusion can be considered. Subsequent treatment can then be tailored to the etiology of shock. Elements of bedside ultrasound examination are currently taught in many anesthesia training programs. ⋯ To develop an approach to the patient in shock that incorporates bedside ultrasound examination.