Charles D. Boucek

Dextromethorphan poisoning reversed by naloxone

Dextromethorphan, a common ingredient in cough syrups, has rarely been described to cause toxicity. The authors describe an unusual case of a known asthmatic presenting with somnolence, who appeared to be in end-stage respiratory failure. Her partial response to routine naloxone, 1 mg, was surprising. However, additional naloxone was required to completely normalize the patients mental status. The authors suggest naloxone be administered in doses of 0.4 mg or more intravenously in suspected dextromethorphan overdose.

A comparison of techniques for placement of double-lumen endobronchial tubes

STUDY OBJECTIVE To compare two methods of double-lumen endobronchial tube placement for thoracic surgery and to identify factors that provide a rational basis for placement method selection. DESIGN Prospective, randomized study. SETTING Teaching hospital. PATIENTS 58 ASA physical status II, III, and IV patients scheduled for surgical procedures requiring elective left-sided endobronchial intubation. INTERVENTIONS Patients were assigned randomly to either a group in which the initial placement method was the traditional approach of placing the endobronchial tube through the larynx and then advanced blindly into the left mainstem bronchus, or to a second group in which the left mainstem bronchus was intubated under direct vision using the fiberoptic bronchoscope. MEASUREMENTS AND MAIN RESULTS Of the 32 patients who underwent the traditional approach, primary success occurred in 27 patients and eventual success in 30. In 27 patients undergoing the directed approach, primary success occurred in 21 patients and eventual success in 25. Two patients in each group required the alternative method. The blind approach took 88 (+/- 91) seconds and the directed approach took 181 (+/- 193) seconds (p = 0.029). Timing data were analyzed using analysis of variance with respect to method and secretions and then t-tests as appropriate. Categorical data were analyzed using the Kruskal-Wallis and Fishers exact tests as appropriate. All values are reported as means +/- SD. CONCLUSION Both the blind and directed approaches resulted in successful left mainstem placement of the endobronchial tube in the majority of patients but either method may fail when used alone. More time was required using the directed approach. Operator experience with both methods will increase the likelihood of success. The choice of the initial approach may be influenced by patient factors as well as available equipment and personnel.

Willingness to perform mouth-to-mouth ventilation by health care providers: A survey ,

BACKGROUND During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patients need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate ones own child was stronger than any other motivator. CONCLUSIONS HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.

Wearing the Wrong Size Latex Surgical Gloves Impairs Manual Dexterity

Universal precautions mandate that health care workers wear gloves when dealing with patients, often in situations requiring a high level of technical skill. Although it seems obvious that wearing the wrong size gloves could impair or prolong tasks involving manual dexterity, the issue has not been formally studied. We tested the hypothesis that wearing the wrong size gloves impairs manual dexterity. We administered a grooved pegboard test to 20 healthy, paid, volunteer health care workers. The subjects performed the test with bare hands and while wearing their preferred size of latex surgical gloves, gloves that were a full size smaller, and gloves that were a full size larger. Each subject did three runs with each size glove and three runs with bare hands. The time necessary to insert pegs was measured with a stopwatch. Peg insertion time was not affected by wearing preferred size gloves (vs. bare-handed) but was increased 7–10% by gloves that were either too small or too large (both effects: P < 0.05 vs. preferred size; both P < 0.001 vs. bare-handed). The subjects reported that the too-small gloves limited hand motion or hurt their hands, whereas the too-large gloves were clumsy but comfortable. Health care workers should wear gloves that fit properly when doing tasks that require manual dexterity. If the preferred size is unavailable, wearing gloves that are too large seems the best alternative.

Portopulmonary hypertension as an indication for combined heart, lung, and liver or lung and liver transplantation: literature review and case presentation.

End‐stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52‐year‐old man had end‐stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double‐lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re‐exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT. Liver Transpl 17:137–143, 2011.

Simulation: a teaching tool for liver transplantation anesthesiology

Aggarwal S, Bane BC, Boucek CD, Planinsic RM, Lutz JW, Metro DG. Simulation: a teaching tool for liver transplantation anesthesiology.

Wearing Ambidextrous Vinyl Gloves Does Not Impair Manual Dexterity

Universal precautions mandate that health care workers wear gloves to prevent the unintended spread of bloodborne pathogens. Gloves may affect manual dexterity, generally delaying task completion. Our previous study showed that wearing the wrong size latex surgical glove degraded manual dexterity. The use of non-sterile and non-latex gloves may limit certain risks and be more cost-effective. However, such gloves may produce different results. We hypothesized that ambidextrous vinyl examination gloves would degrade manual dexterity compared with bare hands. We studied 20 random subjects from a medical environment. Subjects performed a standard battery of Grooved Pegboard tasks while bare-handed, wearing ambidextrous non-sterile vinyl gloves that were their preferred size, a size too small, and a size too large. The order was randomized with a Latin Square design to minimize the effects of time, boredom, and fatigue on the subjects. Subjects were also invited to comment on the fit of different size gloves. Wearing vinyl gloves of both the preferred size and a size up or down failed to affect manual dexterity vs. bare hands on time to insert pegs, and pegs dropped during insertion or removal. In contrast, the time to remove pegs was reduced by wearing preferred size vinyl gloves compared with performing the task with bare hands (P < 0.05). Subjects reported a generally poor fit in all sizes. Vinyl gloves that were too small caused significant hand discomfort. Vinyl gloves surprisingly do not degrade manual dexterity even when worn in ill-fitting sizes. Wearing a preferred size vinyl glove vs. bare hands may improve dexterity in selected tasks. Choosing a comfortable, large size seems the best strategy when the preferred size is unavailable. Thinner vinyl gloves may improve grip and may not degrade touch as much as latex surgical gloves and may thus represent a reasonable choice for selected tasks.

Multivisceral Transplantation: Intraoperative Vascular Access Strategy

Multivisceral transplantation is a complex operation that has been used to replace nonfunctioning intestine and liver with graft organs. The ability to provide hemodynamic monitoring, to rapidly replace blood and other fluids, and to administer medications requires robust vascular access. Multiple previous procedures, prolonged parenteral nutrition, and vascular thrombosis limit accessible sites. Preoperative planning and imaging may reduce vascular injuries and limit delays during preoperative graft ischemia.

Simulation: In Anesthesia for Liver Transplantation

Anesthesia management of liver transplantation patients presents unique challenges because of the complexity of the surgery and the pathophysiology of end-stage liver disease. Experience obtained in this simulation course provides learner with the ability to strengthen their medical knowledge, improve both clinical skills and confidence while reducing anxiety. It promotes both critical thinking and problem solving helping a learner to evolve from resident to consultant level.

Anesthesia for bone marrow harvesting in the prone position in a patient with preexisting pericardial tamponade

Refractory pericardial tamponade developed in an 18-year-old man with recurrent lymphoma. Invasive monitoring guided anesthetic management for bone marrow harvesting for autologous transplantation. The use of the prone position did not lead to adverse hemodynamic effects. The presence of a double pulse was demonstrated by pulse oximetry.