A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Management of Tetralogy of Falot - case presentation of a School going child presenting with central and peripheral Cyanosis, finger nail clubbing Grade IV with a history easy fatiguability and occasional Tet spells since the age of 2.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Management of Tetralogy of Falot - case presentation of a School going child presenting with central and peripheral Cyanosis, finger nail clubbing Grade IV with a history easy fatiguability and occasional Tet spells since the age of 2.
Successful management of massive intra-operative pulmonary embolism Apollo Hospitals
Acute Pulmonary Embolism has a high rate of mortality (26%) due to blockade of the pulmonary artery leading to acute increase in right ventricular pressure causing sudden cardiac decompensation. Lack of specific tests for early diagnosis is one of the causes for high rate of mortality but timely diagnosis and active intervention can save the life of the patient.
Pulmonary Embolism, Case Report of b/l PE & Literature ReviewBadarJamal4
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European Society of Cardiology (ESC), European Respiratory Society (ERS) Recommendations
Pathophysiology
Clinical Manifestations
Diagnostic Algorithms
Management Insight
Anticoagulation guidelines
Choice and duration of Anticoagulation
Indications of Thrombolysis
Follow up for CTEPH
Transitions of Care (OR-PACU) - Aalap Shah , MDAalap Shah
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Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...Aalap Shah
We evaluate the predictive value of patient-reported functional status on hospital length of stay (LOS) and morbidity/mortality for PHTN patients undergoing non-cardiac, non-obstetric procedures at our institution.
The patient handoff is a contemporaneous, interactive process of passing patient-specific information from one caregiver to another to ensure the continuity and safety of patient care. It is well recognized that the handoff is a point of vulnerability where valuable patient information can be distorted and omitted [1, 2]. A plethora of studies in the nursing literature have identified a variety of problems, including incomplete or inaccurate information [3-6], uneven quality [7], repeated interruptions and lack of anticipatory guidance [8]. Many reports have focused on characterizing the weaknesses with non-operative patient handovers, the use of handoff checklists and aviation safety models for specific groups of patients [1,5,9], and the pre- and post-implementation comparisons. [10-12] However, few studies have focused on prospective cohort studies validating and testing patient information management systems such as smart-templates in the setting of handover quality. [10]
Electronic templates containing patient information help to standardize the type of information conveyed during interactions, discourages ambiguous findings,[13] improves provider satisfaction and improves continuity of care.[14] Within the department, we developed the transfer template (T2) to address the issues in provider workflow and efficiency. With the press of a button, the T2 template automatically extracts live information from the anesthetic record, pertinent fields from the PAC note and laboratory values from IView, and provides a concise output of these relevant details.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
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R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
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Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
5. Cases by Patient Age
0
1
2
3
4
5
6
7
8
9
0-1 mon 1-12 mon 1-2 year 3-11 year 12-17 yr 18+ yr
6. Weekend Cases 6/10-6/13
ASA 1 ASA 2 ASA 3
13 y/o M w/ LLE
laceration after ATV
accident I&D
9 y/o M w/ appendicitis
lap appy
1 d/o FT M w/
imperforate anus
colostomy
4 y/o M w/ metastatic
Burkitt’s lymphoma and
lumbosacral involvement
LP
3 y/o M w/ R.
supracondylar fx CRPP
6 y/o M swallowed
wedding ring EGD
removal FB
12 y/o M s/p IR
drainage of pleural
effusion R. VATS
biopsy, pleurodesis
6 m/o F w/ recurrent
retinoblastoma, chemoRx
CVL revision
2 y/o F with LLE FB
removal FB
3 y/o F with spiral
femur fracture after
child fell on her
2 y/o M h/o MRSA
abscesses, buttock
abscess I & D
7 y/o F with B-ALL s/p
induction chemoRx port
revision
11 y/o F w/ open BBFx
I&D + fixation
6 y/o M elbow fx after
monkey bars
PP/repair
22 y/o F Pfeiffer’s sx,
POD11 s/p LeFort III w/
jaw wound I & D
12 y/o F with pelvic rami
and iliac fx after horse
fell on her ORIF b/l
pelvis
17 y/o M punched
window, R. wrist lac
exploration/repair
20 y/o w/ tonsil bleed
POD4 s/p T&A
cauterization
7. 20 y/o for T&A
HPI
• 20 y/o F with recurrent sore throat, R. ear
otalgia, fever, trismus
• PE: 3+ tonsils, reactive cervical
lymphadenopathy
• Scheduled for tonsillectomyPMHx:
- Chronic nasal congestion
- s/p septoplasty (6/2015)
- s/p wisdom teeth extraction
- L. ACL partial tear (2008)
- Concussion/post-concussive syndrome x 2
(9/2010, 5/2011)
Labs (4/2016)
CBC: WBC 9.8, Hct 37.0, Plt 260, PBS wnl
BMP: Na 139, K 3.7, Cl 103, CO2 27, BUN 15,
Cr 0.7
Blood Type: O+
8. 20 y/o for T&A
• Indications for tonsillectomy?
– Sleep-disordered breathing and sleep apnea
• Tonsillar hypertrophy (age 3-6); involution after age 8
• Children with sleep apnea benefit from tonsillectomy, although decreased
efficacy with obesity
– Severe recurrent sore throats
• Cochrane Review 11/2014: 3 vs 3.6 episodes/year (decrease in 0.6/year)
• Recurrent strep infection despite abx
– Various other relative indications (ex, Peritonsillar cellulitis/abscess, dental
malocclusion, hemorrhagic tonsillitis, prevention of secondary rheumatic fever)
• Comorbid conditions with long-standing disease?
– Pulmonary Hypertension, cor pulmonale
– OSA and “adult” comorbidities : DM, HTN, stroke
• How would you induce this patient?
9. 20 y/o - Anesthetic Plan?
• Pre-med: Midazolam
• Airway: 7.0 cETT, Mac 3, Gr 1 view
• Monitors: ASA Standard
• Induction: Propofol/Lidocaine/Fentanyl
• Analgesia: Acetaminophen
• Anti-emetics: Dexamethasone / Ondansetron
NSAIDs also work
• IV Fluids: LR 900cc
• Discharge Rx: Acetaminophen, Oxycodone
11. T&A POD 5…
• BCH ED after spitting up ~1.5 tbsp. of BRB
while taking PO
• To OR for Tonsillar cauterization
– Labs? Hydration? IV?
• WBC 9.8, Hct 37.0, Plt 260, PBS wnl
– Findings: bleeding from R. tonsillar fossa; b/l inferior
poles, EBL “minimal”
12. T&A POD 5…
• What are some common complications?
• Does age or time course of bleeding matter?
• How will you induce her now?
– RSI, Propofol/Succinylcholine
14. Tonsillectomy: Management Pearls
• Children who undergo the procedure for OSA are at particularly high risk
of significant respiratory complications in the postoperative period
• Complications:
– Pre-: Turbulent flow with anxiety/rapid breathing
– Induction: Laryngospasm (↑ incidence vs. general population)
– Intra: secretions, laryngospasm with extubation
– Post: PONV, hypopnea, bleeding*
• Who should be observed overnight?
– Pts. With OSA or evidence of RH dysfunction
The airway is shared between the anesthesiologist and the surgeon and
must be protected from blood and secretions.
15. Tonsillectomy: Bleeding Management
• Post-Tonsillectomy hemorrhage rates = 1.9 –7%
– Undiagnosed bleeding disorders!
• Does timing of bleeding make a difference?
– First 24 hrs: More severe bleeding (usually in first 6 hours)
associated with “cold steel”
– Secondary 5-10 days, after eschar falls off associated with cautery
• Mucosa involution
• Does age make a difference?
– ↑ Incidence with ↑ Age (age 21-30: ~3.7%)
– Prior hemorrhage ~12% risk for repeat hemorrhage
• If bleeding significant, may not be able to obtain Hgb in time
– ↓ baseline SpO2: ominous for ↓ dO2 (d/t anemia)
16. ASA 1 ASA 2 ASA 3
13 y/o M w/ LLE
laceration after ATV
accident I&D
9 y/o M w/ appendicitis
lap appy
1 d/o FT M w/
imperforate anus
colostomy
4 y/o M w/ metastatic
Burkitt’s lymphoma and
lumbosacral involvement
LP
3 y/o M w/ R.
supracondylar fx CRPP
6 y/o M swallowed
wedding ring EGD
removal FB
12 y/o M s/p IR
drainage of pleural
effusion R. VATS
biopsy, pleurodesis
6 m/o F w/ recurrent
retinoblastoma, chemoRx
CVL revision
2 y/o F with LLE FB
removal FB
3 y/o F with spiral
femur fracture after
child fell on her
2 y/o M h/o MRSA
abscesses, buttock
abscess I & D
7 y/o F with B-ALL s/p
induction chemoRx port
revision
11 y/o F w/ open BBFx
I&D + fixation
6 y/o M elbow fx after
monkey bars
PP/repair
22 y/o F Pfeiffer’s sx,
POD11 s/p LeFort III w/
jaw wound I & D
12 y/o F with pelvic rami
and iliac fx after horse
fell on her ORIF b/l
pelvis
17 y/o M punched
window, R. wrist lac
exploration/repair
20 y/o w/ tonsil bleed
POD4 s/p T&A
cauterization
Weekend Cases 6/10-6/13
17. 12 y/o M for VATS biopsy
HPI
• P/w fever, cough, myalgias, congestion, nausea,
vomiting, sore throat, intermittent H/A
• Dx PNA 3 months ago with mild R. pleural effusion
• Treated with CTX complete resolution (per CXR)
PMHx: Born at at 31wks, 2-wks in NICU intubated; Otherwise Healthy
SocHx: From Sudan, travelling through Istanbul to US
PE: Lethargic
- CBC: [6/2]: WBC 5.5, Hct 36, PLT 455; ESR 62, CRP 10, LDH 176 264
- CXR [6/2]: RML/RLL consolidation + R. effusion: c/fPNA + parapneumonic effusion
- CT [6/2]: R. pleural effusion with pleural thickening,
mediastinal + hilar LN: c/f empyema
- Nl ECHO, respiratory cultures, ANA, pleural fluid flow cytometry and various bacterial/fungal cx
Received CG in Sudan, started on Vancomycin/ceftriaxone at BCH
- To IR 6/3: PICC, 10Fr pigtail CT 825 ml serous straw-colored fluid (+400cc up to 6/10)
- Negative induced sputum AFB x 3, but persistent fevers…
- 6/8: Positive Tspot and slightly elevated ADA (suggestive of isolated TB effusion) VATS
18. 12 y/o M for VATS biopsy
• How will you induce this patient and secure airway?
• What are the absolute indications for single/one-lung
ventilation? How can you achieve it?
– Protection (Blood/Pus/need for lavage)
– Vt mismatch (BP/BPCF, ominous bullae, bronchial
disruption)
– VATS
• In addition to ASA standard monitors, what else would
you like to look at?
– Spirometry
– Reliable Pulse oximeter!!!
– ART (Measure PO2(A-a) gradient)
19. OLV - Approach
• Age < 8 yrs
– Mainstem intubation +/- FOB, active/passive ipsilateral decompression
• PRO: Single airway maneuver
• CON: Cannot apply CPAP to nondependent lung; must withdraw tube for TLV
– Bronchial Blocker (individual, coaxial)
• PRO: ETT in situ
• CON: No passive oxygenation to dependent lung, inexperience
• Age > 8 (26+ F)
• Robertshaw tubes (DL ETT)
– PRO: Seals/protects lung (suppurative pus), passive oxygenation and application of PEEP
to dependent lung
– CON: Decreased airway diameter SLETT exchange for ICU, balloon herniation,
inexperience, size
DLETT Placement: OpenAnesthesia.org
20. 12 y/o - Anesthetic Plan?
Pre-med: IV Midazolam
Airway: 6.5 cETT, Mac 3, Gr 1 view
EZ Blocker (41 min)
Monitors: ASA Standard
Induction: IV Propofol/Fentanyl
Analgesia: IV Morphine/Ketorolac
Anti-emetics: IV Dexamethasone/Ondansetron
IV Fluids: LR 300cc
22. OLV - Hypoxemia
• What are your SpO2 goals for this patient?
– What happens to PaO2 with OLV? For how long does
this last?
• What are some predictors of hypoxemia?
• What do you do?
– FOB
– CPAP 10mmHg (at what lung volume? Contraindications?)
– PEEP (dependent lung)
– Pause surgery/OLV
– Compress/clamp ipsilateral PA
23. OLV Hypoxemia - Pearls
• Incidence of hypoxemia (with FiO2 1.0):
– 1950s 20%, 1980s 10%, Today 1%
• V/Q mismatch + shunt (↑ with open chest)
• Prediction of Hypoxemia:
– Hypoxemia (increased A-a pO2 gradient) during TLV
– R > L (higher paO2 in PV return from L side)
– GOOD spirometric PFTs
• Don’t have auto-PEEP
– Baseline restrictive lung disease or severe COPD
• Avoid aggressive hyperventilation
– ↓CO2 Inhibits beneficial hypoxic pulmonary vasoconstriction
in ipsi lung
– Increased alveolar pressures ↓ PBF in dependent lung
24. OLV Hypoxemia – Infants
1. Easily compressible rib cage promotes atelectasis of the
dependent (ventilated) lung
2. ↓ hydrostatic pressure gradient between the dependent and
nondependent lungs expected increase in dependent PBF is
diminished
3. ↓ abdominal hydrostatic pressure gradient ↓ functional
advantage of dependent diaphragm
4. ↑ VO2