Total intravenous anesthesia (TIVA) and target controlled infusion (TCI) were discussed. TCI uses infusion models like Marsh and Schnider to calculate the target effect-site concentration of drugs like propofol and opioids to achieve anesthesia. Monitoring anesthetic depth with tools like BIS or AEP is recommended to optimize drug delivery and avoid overdose. While TIVA is commonly used in adults, data in pediatrics is still limited especially for infants, and propofol requires caution for prolonged sedation in ICU. No consensus was reached on whether volatile or intravenous agents lead to better outcomes in cardiac surgery. Office-based anesthesia requires adequate monitoring, emergency equipment, and staff training for patient safety.
TIVA is a technique of anesthesia involving the induction and maintenance of anesthetic state with IV drugs alone. Shorter context sensitivity half time anesthetic agents like propofol is the universally accepted induction agent of choice widely used as a component of TIVA.
Hypothyroidism and hyperthyroidism have significant clinical effects. Both should be optimized. Anesthesia providers should be able to diagnose and manage.
TIVA is a technique of anesthesia involving the induction and maintenance of anesthetic state with IV drugs alone. Shorter context sensitivity half time anesthetic agents like propofol is the universally accepted induction agent of choice widely used as a component of TIVA.
Hypothyroidism and hyperthyroidism have significant clinical effects. Both should be optimized. Anesthesia providers should be able to diagnose and manage.
Description of TIVA models
Three compartment model
Working principle of Target controlled Infusion
Guidelines for safe conduct of TIVA
NAP 5 recommendations and TIVA
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. TIVA
• Total intravenous anesthesia
– Amnesia and analgesia
• Sedation in intensive care unit
• Day surgery
• Office based anesthesia
– Muscle relaxant
7. Infusion mode for Propofol
• Marsh
– Derived from Gept’s model (1987)
• Regional anesthesia combined propofol infusion
• Total 18 patients
• No BMI data
– Scarecely adequate in the elderly
• Anaesthesia 1998;53:Suppl. 1:61-67
• Ann Fr Anesthn Reanim 2000;19:R027
• For patients less than 70y/o
8. Infusion mode for Propofol
• Modified Marsh
– Anesthesiology 2000;92:399-406
– 20 women (health volunteers), age: 18-60y/o
• Obesity is excluded
• Target concentration 5.4μg/ml
– A biophase model combining the Marsh kinetics and a time to peak
effect of 1.6 min accurately predicted the time course of propofol
drug effect.
9. Infusion mode for Propofol
• Schnider
– Anesthesiology 1998; 88: 1170-1182
– Patient population: 25-81y/o health volunteers
• Patient number: 24
• Body weight: 44.4~123 kg
– Covariates
• Age, gender, height and body weight, lean body mass
• BMI: <43 (M) and <35(F)
10. lower keo demand a higher concentration gradient between plasma and
effect-site to achieve a certain effect-site target concentration,
11.
12. Which is better
• In a recent clinical trial, changes in the BIS correlated better with effect
site concentration predictions by the original Marsh model than with the
Schnider model.
– Anesthesia 2007; 62: 661-6
• Potential benefits with the Marsh II and Schnider models are reduced
hemodynamic and respiratory effects.
– Age is included as a pharmacokinetic co-factor in the Schnider model
15. Fentanyl recipe
• Bolus 3 μg/kg over 30sec
• Followed by 2 μg/kg/hr for 30min
• 1.5 μg/kg/hr from 31-150min
• 1 μg/kg/hr until 30min before skin closure
16. Alfentanil
• The model of Scott
– J Pharm Experiment Ther 1987; 240: 159-166
– More accurate than the model of Maitre
• Anesthesiology 1990;73:66-72
• Anesth Analg 1993;77:801-810
– Clearance mainly dependent on liver metabolism
• Enzyme inhibitor: cimetidine, fluconazole, diltiazem, macrolide (erythromycine),
imidazole
22. Propofol infusion syndrome
• Defined as acute bradycardia progressing to asystole
combined with lipemic plasma, fatty liver enlargement,
metabolic acidosis with negative base excess > 10mmol/l,
rhabdomyolysis or myoglobinuria associated with propofol
infusion.
– Large dose, prolonged duration.
• A hereditary mitochondrial fatty acid metabolism impairment
resembling medium chain acyl-CoA dehydrogenase deficiency
is responsible for the susceptibility to the development of
propofol infusion syndrome.
• Minerva anestesiol 2009;75:339
25. BIS
• Processed EEG
– 40-60: general anesthesia
– >90 awake, memory intact
• Limitations
– Not useful during Ketamine anesthesia
– Insufficient information on effects of N2O, high-dose opioid &
neurologic disease.
– False-elevated BIS
• EMG activity
• High electrode impedances
– Does not predict the moment consciousness returns
26. NEJM 2008
• No difference in awareness.
• Not associated with reduced administration of volatile
anesthetic gases.
• Awareness occurred even when BIS values were within the
target ranges.
27. AEP
• Not significantly affected by opioids.
• Auditory modality is the most receptive sensory channel for
perception during anesthesia.
• Limitations
– False elevated AEP
• EMG activity
– BIS and AAI markedly decreased after administration of myorelaxant . A&A
2008; 107(4): 1290-4
• Noise ??
28. BIS vs AEP
• The range of values obtained at
the time of loss of eyelash reflex
AEP: 15-99
BIS: 39-83
29. BIS vs AEP
• The awake values for AAI were less and showed more variation between
subjects than BIS.
30. Closed loop system
• The input
– Drug delivery (etc. propofol, opioids)
• The output
– evoked potential, bispected index (BIS), blood pressure, pulse rate.
31. Discussion …
• Can anesthetic depth monitoring decrease unnecessary
propofol use?
– Putative early propofol infusion syndrome: typical symptoms without
cardiac involvement.
• Monitor pH, lactate, base excess and creatinine kinase is recommended.
32. Can we applied propofol continuous
infusion for children or even infant ?
33. Infusion mode for Propofol
• Kataria
– Anesthesiology 1994; 80: 104-122
– Patient population: 3-11y/o children receiving body surface surgery.
• Patient number: 53
– Three-compartment pharmacokinetic model
• Weight-adjusting the volumes and clearances significantly improved the accuracy.
34. Infusion mode for Propofol
• Marsh (Pediatric)
– BJA 1991; 67: 41-48
• Marsh (Pediatric)
– Patient population: 1-12y/o children receiving minor surgery
• Patient number: 20
35. Infusion mode for Propofol
• Paedfusor
– BJA 2003; 91: 507~513
– 32 children of ASA status II±III, undergoing elective cardiac surgery or
cardiac catheterization were enrolled.
– The effect of bypass
• system was negative during bypass: -5.5%
• Large volume of distribution (ml): 270: 4600: 1340: 8200
– No outcome data
36.
37. For pediatric anesthesia
• Propofol is not indicated for use in children < 3y/o.
– Pediatric Anesthesia 2004; 14: 374-379
– Still lack of FDA approval
• Propofol is not approved for sedation in pediatric ICU
patients.
• Minerva anestesiol 2009;75:339
38. For MEP monitoring
• J Neurosurg Pediatrics 7:000–000, 2011
– From Texas
– For 10 children age under 3 year old (mean age: 16.8 months)
receiving complex spine surgery
– Sevo induction
– Maintenance: propofol 6-15mg/kg/hr
– No mention of OP time
• Discussion: The loss or absence of MEP amplitude may be minimized
when propofol is administered in small, titrated doses (6-15mg/kg/hr) in a
child younger than 3 years of age.
39. In PICU in Australia and NZ
• The majority of practitioners (82%) use propofol infusion in
children in PICU
– the main indication being for short-term sedation in children requiring
procedures.
• 67% of paediatric intensivists use maximum infusion doses
that may be considered dangerously high (> or = 10 mg/kg/h)
• 19% use propofol infusion for prolonged periods (> 72 hours).
• A smaller proportion (15%) of respondents indicate that they
may use both higher doses and prolonged periods of infusion
• Anaesth Intensive Care. 2002 Dec;30(6):786-93.
40. For prolonged sedation
• Propofol should be used with extreme caution for prolonged
sedation in intensive care unit patients, at dose rates of below
5 mg/kg per h
• Curr Opin Anaesthesiol. 2003 Jun;16(3):285-90
• TIVA with propofol in infants younger than 1 year old requires
extensive experience with TIVA in older children and with the
handling of this special age group and should be undertaken
with maximum precautionary measures.
– Infusion rate up to 9mg/kg/hr over 2-4hours are recommended for
TIVA in children.
• Anaesthesist. 2003 Sep;52(9):763-77.
41. BIS for children
• The Bispectral Index correlates well with the Ramsay score in
the normal sedated child.
• Pediatric Critical Care Medicine: January 2003 ; 4(1) 60-64
43. TIVA in cardiac surgery
• Still no conclusion
– 30-day mortality in acute procedure was significantly lower in the
propofol group.
– 30-day mortality caused by infection, pulmonary causes or renal
causes was significantly lower in the propofol group.
– J Cardiothorac Vasc Anesth 2007;21:664-71
– Volatile anesthetic in AVR: better preservation of myocardial function
and a reduced postoperative release of troponin I.
– Less ICU stay in the volatile anesthetic group.
– Anesth Analg 2006;103:289-96
45. 2008 ASA statement
• A reliable source of oxygen and backup oxygen sources.
• An adequate and reliable source of suction.
• Reliable system for scavenging waste anesthetic gases.
– while inhalation anesthetics are administered…
• Adequate illumination of the patient, anesthesia machine and
monitoring equipment.
– Hard to define adequate illumination.
• Sufficient space to accommodate necessary equipment and
personnel.
– Most critical part in most circumstances in our hospital.
• Sufficient electrical outlets
46. 2008 ASA statement
• Anesthetic equipment
– a self-inflating hand resuscitator bag capable of administering at least
90 percent oxygen as a means to deliver positive pressure ventilation
– adequate anesthesia drugs, supplies and equipment for the intended
anesthesia care
– adequate monitoring equipment
• An emergency cart
– a defibrillator
– emergency drugs
– equipment adequate to provide cardiopulmonary resuscitation
• adequate staff trained to support the anesthesiologist and a
reliable means of two-way communication to request
assistance.
47. 2008 ASA statement
• Appropriate postanesthesia management should be provided.
– Our weak point.
48. Statement on safe use of propofol
• ASA 2009 statement
– The practitioner should be present throughout the procedure and be
completely dedicated to that task.
– manage the potential medical complications of sedation/anesthesia.
– proficient in airway management
– have advanced life support
– understand the pharmacology of the drugs used.
– Monitoring
• Ventilation: Monitoring for the presence of exhaled carbon dioxide should
be utilized because movement of the chest will not dependably identify
airway obstruction or apnea.
• oxygen saturation
• heart rate
• blood pressure.
49. Summary
• Safer environment
– Oxygen supply and suction should be close to the patient.
• Safer equipment
– Emergency cart: defibrillator
– Keep ABC in mind
– End-tidal CO2 monitoring