Natan Weksler

Emergency percutaneous tracheostomy is feasable in experienced hands

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.

Sequential plasmafilter-dialysis with slow continuous hemofiltration: additional treatment for sepsis-induced AOSF patients

Abstract Five patients with sepsis-induced acute organ system failure were treated by sequential plasmafilterdialysis with slow continuous hemofiltration in addition to conventional therapy. In this way, we were able to associate the possible clearance of mediators and toxic substances achieved by plasmapheresis with an improved clearance of nitrogen waste products, since we added diffusion to the convective effect of hemofiltration. The hypercatabolism was well controlled, and there was a significant improvement in cardiorespiratory parameters at the same time. These patients were retrospectively compared with four conventionally treated patients (100% mortality) and with six others treated by association of conventional therapy and continuous arteriovenous hemodialysis (50% mortality). Despite the small numbers of patients treated and the need of additional studies, our good results (all the patients survived) encourage us to use this approach as an adjunct of conventional therapeutic measures in oliguric and hypercatabolic AOSF patients.

Premedication with metoclopramide decreases the frequency of methohexital induced hiccup

Metoclopramide is one of many drugs that have been recommended for the treatment of intractable hiccup. Methohexital may produce hiccup during induction of general anesthesia. 211 women received methohexital for induction and maintenance of general anesthesia for short gynaecological procedures. All the patients were premedicated with fentanyl, diazepam and atropine. 109 patients were randomly selected to receive metoclopramide before induction of anesthesia; the remaining 102 patients served as a control group, and were anesthetized without metoclopramide premedication. The frequency of hiccup was compared between the two groups. 7 patients had hiccup in the metoclopramide premedicated group, as compared to 17 patients in the control group. This difference was statistically significant. We conclude that metoclopramide reduces the frequency of methohexital induced hiccup, and recommend that metoclopramide be routinely used for the premedication of methohexital injection.

Optimization of Endotracheal Tube Cuff Pressure by Monitoring Co: A Randomized Controlled Trial2: A Randomized Controlled Trial Levels in the Subglottic Space in Mechanically Ventilated Patients: A Randomized Controlled Trial

BACKGROUND Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. METHODS This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. RESULTS Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). CONCLUSIONS This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group. Thus, the use of automatic cuff pressure control based on subglottic measurements of CO2 levels is an effective method for ETT cuff pressure optimization. The method is safe and can be easily utilized with any intubated patient.BACKGROUND Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. METHODS This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. RESULTS Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). CONCLUSIONS This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group. Thus, the use of automatic cuff pressure control based on subglottic measurements of CO2 levels is an effective method for ETT cuff pressure optimization. The method is safe and can be easily utilized with any intubated patient.

Non Cardiogenic Pulmonary Edema as Consequence of Upper Airway Obstruction

Non cardiogenic pulmonary edema is a rare complication of upper airway obstruction. Its etiology is controversial, but probably can be explaired by the Starling’s law, when the large negative intrathoracic pressure generated excedes the intravascular and interstitial pressures, shifting fluids from capillaries to interstitium and alveoli. In addition, alteration of capillary permeability potentiates fluid migration.We present herein, a case of non cardiogenic pulmonary edema following relief of upper airway obstruction in a 14 years old girl underwent surgical repair of cleft palate.Cardiogenic pulmonary edema could be excluded by a normal CVP, wedge pressure and four chamber echocardiography. The edema fluid: plasma protein ratio greater than 0.7 can indicate an increased capillary permeability. Mendelson’s syndrome could be ruled out by the rapid improvement seen and the soft clinical course.

No sensory block with spinal bupivacaine a case report.

We report a case in which 2 cc of 0.5% plain bupivacaine was injected intrathecally in the lateral position at the level of L2-L3 interspace, as a result of which motor and sympathetic blockade developed, and mild paraesthesia (partial sensory blockade). We speculate that in this case plain bupivacaine acted as hypobaric solution and after repositioning of the patient into the supine position the solution passed anteriorly, blocking the motor and sympathetic roots, but not completely blocking the sensory (posterior) roots.

Preliminary Study of Epidural Nalbuphine Treatment of Post Operative Pain: A Comparison with Equipotent Dose of Epidural Morphine

AbstractEpidural analgesia was used in 45 patients submitted to upper abdominal surgery. In 30 of them 0.15 mg/kg nalbuphine (EN group) was injected and in the remained, an equipotent dose of 0.1 mg/kg of preservative free morphine (EM group) was used. The patients were observed concerning the severity of pain before and after narcotic administration, duration of analgesia, occurence and severity of side effects among them. The severity of pain was stated by the McGill pain score (from 0 to 5). Duration of analgesia was defined as the time interval from pain relief after narcotic administration untill requirement of an additional epidural narcotic injection. The adequacy of ventilation was estimated by sequential measurements of arterial

Terlipressin facilitates transport of septic patients treated with norepinephrine

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