Sanford M. Miller

Monitoring for suspected pulmonary embolism

It is fortunate that serious embolic phenomena are uncommon because, with the exception of neurosurgery in the sitting position and cardiac surgery, thoracic echocardiography and the precordial Doppler device, the most sensitive indicators of embolism, are seldom used. Vigilance is required of the anesthesiologist to recognize the rapid fall in end-tidal PCO2, the usual first indicator of a clinically significant PE. Any sudden deterioration in the patients vital signs should include embolism in the differential diagnosis, particularly during procedures that carry a high risk of the complication.

The use of cardioselective β-blockers in a patient with idiopathic hypertrophic subaortic stenosis and chronic obstructive pulmonary disease

Abstract The β-adrenergic receptor blocking drugs are commonly used in the treatment of patients with idiopathic hypertropic subaortic stenosis (IHSS). These drugs, however, are contraindicated in patients with chronic obstructive pulmonary disease (COPD). We report the anesthetic management of a patient with IHSS complicated by severe COPD. We concluded that the β 1 selective, ultra-short acting β-blocker, esmolol, can be used intraoperatively when both conditions are present. The pathophysiology and the commonly used anesthetic drugs and practices for treatment of patients with IHSS are reviewed.

How Much Evaluation of the Airway Is Essential Prior to Anesthesia

With the availability of advanced airway management devices and algorithms, airway assessment for difficult laryngoscopy and intubation may be considered less important by some clinicians. Inability of any airway assessment test to provide absolute prediction of difficulty further decreases the importance of airway evaluation. However, proper evaluation of the airway aids in planning the appropriate technique to be used and thus reduce the likelihood of complications such as aspiration, airway obstruction and airway trauma during airway intervention.

Airway Management in Trauma

Ultimately, the goal of airway management in trauma is to establish and/or maintain adequate oxygenation, ventilation, and airway protection. It is the first priority in the acute phase of care of the trauma patient and consists of evaluation and, when indicated, intervention using various techniques and devices. It involves the recognition of any trauma to the airway or surrounding tissues, anticipation of their respiratory consequences, and planning and application of management, keeping in mind the potential for exacerbation of existing airway or other injuries by the contemplated strategies. It also involves prediction and prevention of progression of airway or surrounding tissue injury with increasing airway compromise.

General Principles of Intraoperative Management of the Severe Blunt or Polytrauma Patient: The Resuscitative Phase

There has been a significant breakthrough in the treatment of the severely injured trauma patient as a result of a growing consensus based on evidence-based goal-directed therapies. Through developments in science and technology, a consensus on blood product administration, patient monitoring, understanding of blood clot stability, ventilation of the trauma patient, and fluid administration has taken place among trauma centers. In addition, the rapidly developing field of interventional radiology has offered the possibility of controlling bleeding when surgery cannot. Trauma centers have configured themselves to have an operating room near the interventional suite, which are both near the blood bank and point-of-care testing laboratories. “Shrinking the circulation” with vasopressin and keeping the mean blood pressure low to control blood loss, and correction of an ongoing coagulation disorder, is now rooted in many centers’ strategy aimed at optimal survival. Cerebral oximetry, thromboelastography, thromboelastometry, pulse pressure variation, core temperature monitoring, and other point-of-care tests are now common and are no longer considered new technology. While trauma anesthesiologists do not have a uniform mode of practice, we are very rapidly getting close to that.

Thoracic and Abdominal Injuries

Injuries to the thorax and the abdomen—the torso—contribute significantly to trauma-related mortality and morbidity. While the vulnerability of the closely organized vital organs to injury in this region plays an important role in morbidity and mortality, the noncompressible nature of hemorrhage in this area also contributes immensely to otherwise preventable trauma deaths. While it is estimated that one fourth of trauma deaths is secondary to chest trauma alone and claims about 16,000 lives per year [1], hemorrhage in the torso (thorax, abdomen, and pelvis) also results in a mortality of as much as 70–80 % after otherwise survivable noncerebral and noncardiac injuries in both civilian and military populations [2]. The overall mortality from exsanguination, which remains second to central nervous system (CNS) injury as a cause of death, primarily originates from injuries of the thorax, abdomen, and pelvis; there has been a reduction in death from extremity bleeding because of effective control with tourniquets or topical hemostatic agents, but not from torso bleeding. With increasing use of anticoagulant agents for prophylaxis and management of cardio- and cerebrovascular disorders, bleeding-related mortality from truncal injuries is probably more frequent. For example, the predominant injury site in patients with cardiovascular disease who died after trauma in one study was chest in 15 % and abdomen in 3 % of instances; head and neck was the injury site in 69 % of patients [3].

INITIAL EVALUATION AND RESUSCITATION

The immediate care required by most severely injured patients is best managed with a multidisciplinary approach. Thus the medical team, usually consisting of a trauma surgeon, an emergency physician, and an anesthesiologist, works together, with the trauma surgeon directing the care. In centers where the anesthesia department puts a strong emphasis on trauma care, the anesthesiologist(s) and the trauma surgeon(s) are called to the emergency room (ER) simultaneously. Even in institutions where this policy does not exist, the anesthesia staff is often likely to be called to the ER before the surgeon completes the initial management. Obviously, physicians with different backgrounds must be provided with the basic clinical concepts, knowledge, and skills that stem from a common source for initial management to proceed in a coordinated manner with clear, rapid, and accurate communication. The Advanced Trauma Life Support (ATLS) Course, developed by the Committee on Trauma of the American College of Surgeons (ACS), provides a standard source of information about early trauma care and greatly helps in the achievement of this objective. Unfortunately only a small fraction of physicians (about 2%–3%) who have been attending this course since its introduction 15 years ago are anesthesiologists. This discussion will combine the relevant aspects of ATLS guidelines with principles of preanesthetic evaluation to provide a summary of the initial management of the trauma patient for the anesthesiologist. In principle, assessment and resuscitation proceed together during the early stage of trauma care. In most instances, however, oxygenation and circulation are stable, allowing for enough time to obtain a reasonable medical history and establish a diagnosis. Effective management by the trauma team requires evaluation of the nature of the injury, recognition of injury-related and/or preexisting physiologic derangements, prediction of short- and long-term complications, and timely optimization of organ perfusion and oxygenation. Achieving these goals requires a well-designed clinical strategy.