Aneasthesia Pearls November 2012

ANAESTHESIA PEARLS
  • Preloading or Co-loading……. Crystalloids or Colloids………….in LSCS

Preloading or Co-loading
  • Comparison between the four possible intravascular loading regimens for the prevention and treatment of maternal hypotension in LSCS.

Intravascular Comparison
Christian Loubert Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: Continuing Professional Development
    • The key attributes of a good anaesthetist are

   Self-reliance and the ability to assess the severity of life-threatening conditions, as well as initiate emergency treatment
An understanding of their own limitations and the need to call for help
Attention to detail (especially with regard to monitoring and record-keeping)
Good communication skills with relatives and patients
Good interpersonal skills to deal with all members of the theatre team
Reliable
Ability to self-motivate
Punctuality
Flexibility
A good team-player
Reasonable manual dexterity
Ref:
How to get started in anaesthesia, Anaesthesia UK
  • Case Scenario: Perianesthetic Management of Laryngospasm in Children

Ref:
Orliaguet, Gilles A. M.D., Ph.D.*; Gall, Olivier M.D., Ph.D.†; Savoldelli, Georges L. M.D., M.Ed.‡; Couloigner, Vincent M.D., Ph.D.§
Anesthesiology:February 2012 – Volume 116 – Issue 2 – p 458–471
Case Scenario
Perioperative laryngospasm is an anesthetic emergency that is still responsible for significant morbidity and mortality in pediatric patients.
The first step of laryngospasm management is prevention.
The second step relies on the emergent treatment of established laryngospasm occurring despite precautions.
Training and simulation on the management of laryngospasm in children:
Supplemental Digital Content
  • Magnesium and Laryngospasm

Preloading or Co-loading
Laryngospasm is the most common cause of upper airway obstruction after tracheal extubation. Magnesium has a central nervous system depressant property, which contributes to the depth of anaesthesia. It also has calcium antagonist properties, which provide muscle relaxation.
To determine the effect of magnesium on preventing laryngospasm, 40 patients, ASA I–II, aged 3–12 years, who were scheduled for tonsillectomy or/and adenoidectomy, were randomly divided into two groups.
After intubation, patients in group I received 15 mg•kg−1 magnesium in 30 ml 0.9% NaCl over 20 min. Patients in group II received 0.9% NaCl alone.
All patients were extubated at a very deep plane of anaesthesia.
Laryngospasm was not observed in group I, it was observed in five patients in group II (25%)
This study concluded the decrease in the incidence of laryngospasm in paediatric patients receiving magnesium.
It is suggested that the use of intravenous magnesium intraoperatively may prevent laryngospasm.
Ref:
 The use of magnesium to prevent laryngospasm after tonsillectomy and adenoidectomy:a preliminary study

  • The Laryngospasm Notch Technique – C.Philip Larson

This method involves the application of digital pressure at the “laryngeal notch”.
This notch is located behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adajacent to the condyle, posteriorly by the mastoid process of the temporal bone and cephalad by the base of the skull.
skull image
The therapist presses very firmly inwardly toward the base of the skull on each side using either the index or middle fingers while at the same time lifting the mandible at a right angle to the plane of the body (forward displacement of the mandible or jaw thrust).
Peadiatric Unilateral
Paediatric unilateral
Properly performed, it will convert laryngospasm within one or two breaths to laryngeal stridor and in another breath or two to unobstructed respiration. One can simultaneously hold the mask over the face with the thumbs to augment the inspired oxygen concentration.
Adult Bilateral
Adult Bilateral
Adult bilateral
Why does it work?
It’s unclear about the mechanism behind why this works. Here are some theories:
 You are just performing a jaw-thrust maneuver.
 You are providing a deep painful stimuli, which causes the vocal cords to relax.
 You are stimulating deep cranial nerves which happen to also stimulate the vagus nerve.
 Bending the styloid process and producing periosteal pain is another explanation
Ref:
 CLINICAL ANESTHESIOLOGY G.Edward Morgan 3rd Edition
Posted in ANAESTHESIA PEARLS 2012

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