The document discusses extubation of difficult airways. It notes that while respiratory adverse events at induction of anesthesia have decreased, rates of death or brain damage during tracheal extubation have remained unchanged, suggesting more education is needed. Among failed extubation claims since 2000, 94% resulted in death or permanent brain damage. The document provides definitions for extubation failure and at-risk extubation. It discusses patient risk factors and causes of extubation failure, and reviews guidelines from the American Society of Anesthesiologists and Difficult Airway Society for developing an extubation strategy.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
anaesthesia Breathing circuits and its classification and functional analysisprateek gupta
anaesthesia breathing circuits. mapleson circuits. classification of circuits. functional analysia of circuits. draw over circuit. advantages and disadvantages of different circuits.
ASA Guidelines for Management of the Difficult AirwaySun Yai-Cheng
Practice Guidelines for Management of the Difficult Airway
An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013; 118(2):251-270
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
anaesthesia Breathing circuits and its classification and functional analysisprateek gupta
anaesthesia breathing circuits. mapleson circuits. classification of circuits. functional analysia of circuits. draw over circuit. advantages and disadvantages of different circuits.
ASA Guidelines for Management of the Difficult AirwaySun Yai-Cheng
Practice Guidelines for Management of the Difficult Airway
An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013; 118(2):251-270
Rapid sequence intubation (RSI) is a technique that is used when rapid control of the airway is needed as a precaution for patients that may have a 'full stomach' or other risks of pulmonary aspiration. A short description about RSI procedure according to IQARUS guideline.
Dr. Ummay Sumaiya
ICU DOCTOR
| IQARUS | Medical Treatment Facility / IQARUS - Cox’s Bazar - Bangladesh |
Mail: Ummay.Sumaiya@iqarus.com
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. Extubation of the difficult airway
Helga Komen, MD
Department of Anesthesiology
Washington University in St Louis Medical School
2. …How big is a problem?
• In claims for injuries due to inadequate
airway management, respiratory adverse
events causing death or brain damage at
induction of anesthesia have decreased over
the past years, while tracheal extubation
and/or recovery are still associated with an
unchanged rate of death or brain damage,
suggesting that education and guidance in
this area are still needed.
Peterson 2005, Langeron 2006.
4. Among claims for failed extubation
reported since 2000, death and
permanent brain damage occurred in 15
of 16 claims (94%), and there were 8
claims with difficult airway management
that occurred post-extubation in the
recovery period, all (100%) resulting in
death/brain damage.
Personal communication from Karen Posner PhD—Laura Cheney Professor in Anesthesia
Patient Safety, Department of Anesthesiology, University of Washington on November 10, 2011
5. Definition/s
• Extubation failure – inability to tolerate removal of
the translaryngeal tube
– Mechanisms – airway obstruction due to laryngospasm,
upper airway edema, bleeding, secretions, tracheal
colapse, opioids, muscle relaxants
• At-Risk Extubation – the ability of patient to maintain airway
patency and/or oxygenation after tracheal extubation is
uncertain
• Difficult extubation - `difficult decanulation of the airway`
• Weaning failure – inability to tolerate spontaneous breathing
without ventilatory support
6. • Extubation failure
– Early reintubation – mins up to 6 hours after
extubation (most frequently 0-2 hrs, it is rare….0.1-
0.45%)
• Resp. Insufficiency, airway obstruction (laryngeal edema),
bronchospasm, prolonged neuromuscular blockade, side effects of
opioids
– Late reintubation – events occurring between 6
and 72 hours after extubation
Definition/s
Cavallone L, Anesth Analg 2013;116(2):368-83
7. …at increased risk for extubation failure
• Obesity/OSA
– BMI >30kg/m2 (34% of population)
– ↑incidence of difficult mask ventilation
– ↑risk of pulmonary aspiration
– ↑airway obstruction
– ↑rapid oxygen desaturation
– Postop concerns:
• Opioids vs. resp. depression, hypoxia, patient positioning,
adequate monitoring
– ↑major airway complications
8. • Head and neck pathology/surgery
– Reintubation rate 0.7-11.1%
• Obstetrics – edema of the airway, obesity
• Cervical spine surgery (anterior) - >5hrs, >3 vertebral
levels, >300ml blood loss. !! Close respiratory
monitoring up to 48hrs.
– Pharyngeal edema, vocal cord paralysis, hematoma
…at increased risk for extubation failure
9. Causes and mechanisms of extubation failure
• Pharyngeal obstruction – mismatch between bony/soft tissue
amount, ↓tension of pharyngeal wall, retropharyngeal
hematoma, secretions
• Laryngeal obstruction – edema, laryngospasm (contraction of
adductor muscles of vocal cords) – NPPE! (0.1%), vocal cord
paralysis (uni-, bil-)
• Postoperative bleeding – hematoma compressing airway
• Masses and lesions - mediastinal
• Drugs – opioids, muscl. blockade
10. So, how to avoid extubation failure?!
• Current recommendations
– ASA, Anesthesiology, 2013.
• Practice Guidelines for Management of the Difficult
Airway - An Updated Report by the American Society of
Anesthesiologists Task Force on Management of the
Difficult Airway
– DAS, Anesthesia, 2012.
• Difficult Airway Society Guidelines for the
management of tracheal extubation
12. ASA guidelines 2013.
Strategy for Extubation of the Difficult Airway
• The literature does not provide a sufficient basis for
evaluating the benefits of an extubation strategy for
the difficult airway.
– For the purpose of this Guideline, an extubation strategy is
considered to be a logical extension of the intubation
strategy.
13. Recommendations
• The anesthesiologist should have a pre-formulated
strategy for extubation of the difficult airway.
• This strategy will depend, in part, on the surgery, the
condition of the patient, and the skills and
preferences of the anesthesiologist.
ASA guidelines 2013.
14. The preformulated extubation strategy should include:
1. A consideration of the relative merits of awake extubation versus extubation
before the return of consciousness.
2. An evaluation for general clinical factors that may produce an adverse
impact on ventilation after the patient has been extubated.
3. The formulation of an airway management plan that can be implemented if the
patient is not able to maintain adequate ventilation after extubation.
4. A consideration of the short-term use of a device that can serve as a guide for
expedited reintubation. This type of device can be a stylet (intubating bougie) or
conduit.
- Stylets or intubating bougies are usually inserted through the lumen of the tracheal tube and into the
trachea before the tracheal tube is removed. […] Conduits are usually inserted through the mouth and
can be used for supraglottic ventilation and intubation The ILMA and LMA are examples of conduit.
ASA guidelines 2013.
15. Pros and cons of awake versus asleep
extubation
Fully awake
• Pros = complete recovery of airway protective reflexes and effective
spont. breathing are present and may increase safety in the
presence of possible difficult re-intubation.
• Cons = active protective airway reflexes may lead to increased risk
of re-bleeding at the site of surgery (increased venous pressure and
straining on wound).
• Caveats= if pt. awake but NOT calm and cooperative, safe
extubation procedures (e.g. flexible laryngoscopy, correct
positioning of tube exchanger) may be extremely difficult…
16. Pros and cons of awake versus asleep
extubation
Asleep (regular and effective spont. breathing must be
present)
• Pros = pt still anesthetized avoids coughing and fighting ventilator which
would lead to increased risk of re-bleeding at the site of surgery (due to
increased venous pressure and straining on sutures.)
• Cons = lack/decrease of protective airway reflexes may lead to increased
risk for aspiration and airway obstruction;
• Caveats= easy pre-operative intubation and mask ventilation are
important prerequisites; increased risk of laryngospasm if performed
during transition between deep anesthetized state and awake state…
17. Should I even consider asleep (deep)
extubation?
ASA: consider the relative merits…
DAS: Deep extubation is a technique that should be
reserved for spontaneously breathing patients with
uncomplicated airways and only performed by
clinicians familiar with the technique.
18. The preformulated extubation strategy should include:
1. A consideration of the relative merits of awake extubation versus extubation
before the return of consciousness.
2. An evaluation for general clinical factors that may produce an adverse
impact on ventilation after the patient has been extubated.
3. The formulation of an airway management plan that can be implemented if the
patient is not able to maintain adequate ventilation after extubation.
4. A consideration of the short-term use of a device that can serve as a guide for
expedited reintubation. This type of device can be a stylet (intubating bougie) or
conduit.
- Stylets or intubating bougies are usually inserted through the lumen of the tracheal tube and into the
trachea before the tracheal tube is removed. […] Conduits are usually inserted through the mouth and
can be used for supraglottic ventilation and intubation The ILMA and LMA are examples of conduit.
ASA guidelines 2013.
19. How do we perform a quantitative cuff-leak test?
Pt. mechanically ventilated with CMV:
1) measurements of expiratory tidal volumes
after 4-6 complete respiratory cycles with the
ETT cuff deflated
2) measurements of expiratory tidal volumes
with cuff deflated ONLY at the end of the
end-inspiratory pause.
G Prinianakis et al “Determinants of the cuff-leak test: a physiological study”
Critical Care 2005, 9: R24-R31
Miller RL, Chest 1996;110:1035-40
RS Sandhu et al. J Am Coll Surg 2000; 190/6: 682-687.
S Jaber et al. Intensive Care Med 2003; 29:69-74
D De Backer Critical Care 2005;9:31-33
20. How much should the leak be?
Proposed cut-off values in the literature:
• 10-12% of the TV that was measured before cuff deflation
(average-adult population)
• 110-130 ml (average – adult population)
Miller RL, Chest 1996;110:1035-40
RS Sandhu et al. J Am Coll Surg 2000; 190/6: 682-687.
S Jaber et al. Intensive Care Med 2003; 29:69-74
D De Backer Critical Care 2005;9:31-33
21. How much should the leak be?
Positive and Negative predictive value of the test:
• cuff leak < 110 ml = 0.80 PPV for post-extubation stridor
(predicts presence of stridor in 80% of pts)
• cuff leak > 110 ml = 0.98 NPV for post-extubation stridor
(predicts absence of stridor in 98% of pts)
RL Miller et al. “Association between reduced cuff leak volume and postextubation Stridor”
Chest /110/4/October, 1996, 1035-1040. Miller RL, Chest 1996;110:1035-40
22. The preformulated extubation strategy should include:
1. A consideration of the relative merits of awake extubation versus extubation
before the return of consciousness.
2. An evaluation for general clinical factors that may produce an adverse
impact on ventilation after the patient has been extubated.
3. The formulation of an airway management plan that can be implemented if the
patient is not able to maintain adequate ventilation after extubation.
4. A consideration of the short-term use of a device that can serve as a guide for
expedited reintubation. This type of device can be a stylet (intubating bougie) or
conduit.
- Stylets or intubating bougies are usually inserted through the lumen of the tracheal tube and into the
trachea before the tracheal tube is removed. […] Conduits are usually inserted through the mouth and
can be used for supraglottic ventilation and intubation The ILMA and LMA are examples of conduit.
ASA guidelines 2013.
23. Options?
• Reintubation ? (…over an AEC)
• Supra-glottic airway? (for
ventilation/reintubation)
• Tracheostomy? (if swelling expected to be
persistent…)
24. The preformulated extubation strategy should include:
1. A consideration of the relative merits of awake extubation versus extubation
before the return of consciousness.
2. An evaluation for general clinical factors that may produce an adverse
impact on ventilation after the patient has been extubated.
3. The formulation of an airway management plan that can be implemented if the
patient is not able to maintain adequate ventilation after extubation.
4. A consideration of the short-term use of a device that can serve as a guide for
expedited reintubation. This type of device can be a stylet (intubating bougie) or
conduit.
- Stylets or intubating bougies are usually inserted through the lumen of the tracheal tube and into the
trachea before the tracheal tube is removed. […] Conduits are usually inserted through the mouth and
can be used for supraglottic ventilation and intubation The ILMA and LMA are examples of conduit.
ASA guidelines 2013.
25. 11.0 Fr; L = 100 cm; ID = 2.3 mm
14.0 Fr; L = 100 cm; ID =3.0 mm
19.0 Fr; L= 56 cm; ID = 4.7 mm
27. Should a patient with an AEC in situ decompensate,
tracheal re-intubation is the key management strategy.
Supplemental oxygen can be
provided using standard techniques
prior to intubation.
Oxygen insufflation through an AEC appears to be associated
with a lower risk of volutrauma or barotrauma, but […] it is not
risk-free.
L Duggan, Can J Anesth/J Can Anesth (2011) 58:560–568
Use AEC for re-intubation
33. Specific strategies for extubation of
OSA/obese patients
Seet E, Chung F. Can J Anesth (2010) 57:849-864.
Gross JB, Bachenberg KL, Benumof JL et al. Anesthesiology (2006) 104:1081-93
35. Conclusions
• Extubation failure may lead to fatal outcomes
• Situations at risk are frequently recognizable
• Official Guidelines for extubation of difficult
airway
– ASA 2013.
– DAS 2012.
• Absence of large randomized trials (only expert opinions)