VBGs will not replace ABGs

Arterial blood gas (ABG) analysis is often used in to evaluate pulmonary function in critically ill ED patients.

In recent years, venous blood gas (VBG) analysis has replaced ABG analysis for assessing acid-base status (pH, HCO₃^-) in conditions such as DKA.

Some key points about the VBG for assessing pulmonary function:

• VBG does not replace an ABG in determining the exact P_aO₂
• The agreement between the VBG and ABG PCO₂ is often poor and unpredictable
• There is emerging literature on the use of VBG PCO₂ as a screen for hypercarbia but more data is needed

Bottom line: With the possible exception of screening for hypercarbia, VBG has limited utility in the assessment of pulmonary function.

Kelly AM. Can venous blood gas analysis replace arterial in emergency medical care? Emerg Med Australasia 2010;22:493-498

Side effects of Electroconvulsive Therapy

Cardiovascular:

-Initial parasympathetic discharge: prominent during the first ECT treatment, bradycardia, asystole, premature atrial/ventricular contractions. Hypotentsion

-Sympathetic discharge follows: tachycardia, hypertension, PVCs, rarely VT. Usually tachycardia is self limited, peaking at 2 minutes

-EKG changes: ST-segment depression and T-wave inversion

Central Nervous System:

-headache, short-term memory loss, confusion, agitation, increased blood flow and CMR, elevated intraocular pressure

Neuroendocrine:

-increased stress hormones: ACTH, cortisol, vasopressin, prolactin, GH, epinephrine and NE

-improvement in NIDDM and hyperglycemia with IDDM

Gastrointestinal tract:

-elevated intragastric pressure

Schedule/Cancel the surgery...

The dicision whether to proceed with surgery in any child with URTI requires careful risk/benefit analysis on an individual basis and is summarized in the table below.

Schedule	Cancel
Clear runny nose	Child < 1 yr
Dry cough	Purulent nasal discharge
Minor surgery	Productive cough
	Wheezing/crepitations on auscultation
	Systemic features of being unwell, i.e. fever>38, malaise, headache, feeding problems
	Parental confirmation of child being unwell

Also consider patient co-morbidities, type or urgency of surgery, and experience of anaesthetist.

Bart's Tips for successful TBI...part 2

Temperature mangement

Therapeutic hypothermia has shown great improvement in the cardiac arrest victims, however for the injured brain: “There is no evidence that hypothermia is beneficial in the treatment of head injury”.

Therapeutic hypothermia in the injured brain has resulted in more cases of coagulopathy, pneumonia and sepsis.

Bart’s recommend’s we should focus on “therapeutic normothermia” for these patient’s we know cooling is bad, but also fevers and hyperthermia is also detrimental as well.

We know fever increases cerebral metabolic rate and oxygen consumption with associated poor outcomes, however there is currently no good outcome studies to support this.

Take home point: fevers can develop quickly (yes even while the patient is still in ED), so monitor closely and treat aggressively.

Blood pressure

Patients with a severe brain injury often present with an abnormal blood pressure.

Hypotension is profoundly detrimental to these patient and needs to be treated aggressively to maintain cerebral perfusion pressure.

Hypertension can occur through the underlying physiological response to raised ICP, due to an underlying medical condition or may be related to pain and anxiety.

Treatment is generally not recommended in the hypertensive patient, remember these patients require sedatives and analgesia when intubated — providing this can relieve some of the hypertension.

On the rare occasion that you have to treat the high blood pressure, use short acting anti-hypertensive only and dose very gingerly

Cardiac arrest..The prognostic factors

Prognostic factors in out-hospital arrest

1. Public vs Workplace
2. Age old vs young
3. CPR by bystander
4. Time to defibrillation: after or before EMS
5. Time of day Midnight vs AM
6. Gasping

Prognostic factors in in-hospital arrest

1. Rhythm: VF/VT
2.Time to CPR and defibrillation
3. Hospital location: ward vs ICU, Dialysis
4.Time of day
5.AED use

Prognostic factors intra-arrest

PETCO2: 10 @ 20 is bad!!!
Ultrasonography: Cardiac standstill means failed resuscitation regardless of rhythm or monitor

Emergency Medicine Clinics of North America ,issue Feb 2012

Bart Besinger’s Tips for TBI - Part 1

This week we will discuss Bart'sTips for TBI,it entails 5 topics:

Positioning,cervical collar,Blood Pressure,Blood sugar,and Temperature.

Today we discuss the first two items:

Patient Position

Elevating the head of the bed to 30° — will decrease ICP via displacing the CSF and increasing venous outflow.

By elevating the head of the bed to between 30°-45° also decrease the risk of developing ventilator associated pneumonia.

However elevating the head of the bed can be difficult in the patient with spinal precautions.

Bart also recommends avoiding the trendelenburg position (especially when inserting central lines) as this intervention offer’s little benefit but can greatly increase the ICP.

Cervical Collar

C-Spine collar aka “The Brain Tourniquet”.

Clearing the cervical spine of these patients can often be difficult in the comatosed intubated patient.

Removal of the C-spine collar has been showen to decrease ICP by around 2-5 mmHg.

If you are unable to remove the cervical collar check the position, size and tightness of the collar. Bart’s tip: loosen it up a bit so it aids venous return but still supports the head

Bilateral Total Knee Arthroplasty: A Major Morbid Condition!

Bilateral Total Knee Arthroplasty: Risk Factors for Major Morbidity and Mortality

Anesth Analg 2011

Background: Bilateral total knee arthroplasty (BTKA) performed during the same hospitalization carries increased risk for morbidity and mortality compared with the unilateral approach. However, no evidence-based stratifications to identify patients at risk for major morbidity and mortality are available. The objective of the study was to determine the incidence and patient-related risk factors for major morbidity and mortality among patients undergoing BTKA.

Methods: Nationwide Inpatient Survey data collected for the years 1998 to 2007 were analyzed and cases of elective BTKA procedures were included. Patient demographics, including comorbidities, were analyzed and frequencies of mortality and major complications were computed. Subsequently, a multivariate analysis was conducted to determine independent risk factors for major morbidity and mortality.

Results: Included were 42,003 database entries, representing an estimated 206,573 elective BTKAs. The incidence of major in-hospital complications and mortality was 9.5%. Risk factors for adverse outcome included advanced age (odds ratios [ORs] for age groups 65–74 and >75 years were 1.88 [confidence interval, CI: 1.72, 2.05] and 2.66 [CI: 2.42, 2.92], respectively, compared with the 45–65 years group), male gender (OR: 1.54 [CI: 1.44, 1.66]), and a number of comorbidities. The presence of congestive heart failure (OR: 5.55 [CI: 4.81, 6.39]) and pulmonary hypertension (OR: 4.10 [CI: 2.72, 6.10]) were the most significant risk factors associated with increased odds for adverse outcome.

Conclusions: Patient-related risk factors for major morbidity and mortality in patients undergoing BTKA are identified. Although it is beyond the scope of this article to provide final and specific guidelines, the authors would urge institutions to engage in discussions to establish criteria to restrict BTKA procedures to patients with decreased reserve of the cardiopulmonary, vascular, renal, and central nervous system and contemplate exclusion of patients of advanced age and those with evidence of significant end-organ disease. Until detailed evaluation guidelines can be agreed on, it seems prudent to exclude the elderly and patients with ASA physical status 3. Patients at risk for occult derangements of pulmonary hemodynamics and right heart dysfunction (i.e., the obese and those with sleep apnea, chronic obstructive pulmonary disease, and previous pulmonary embolism) should undergo cardiopulmonary evaluation with echocardiography to rule out significant preexisting increases in pulmonary artery pressures, which may predispose patients to increased morbidity and mortality. These data can be used to aid in the selection of patients for this procedure.

Is anesthesia associated with impaired vaccine efficacy?

Vaccination and Anesthesia

Vaccines are broadly classified into two categories, that is, live attenuated (BCG, MMR) or inactivated (IPV).

Rash and fever are common 7–10 days after MMR, parotitis 3 weeks after MMR, and local reactions and fever within 48 h of DtaP/IPV/Hib.

In a survey of anaesthetists by Short and colleagues, 60% of the respondents stated that they would not delay anaesthesia for elective surgery in a recently immunized child, while 40% would postpone for a week for inactive vaccines and 3 weeks for live vaccine.

As a conclusion, misinterpretation of vaccine-related adverse events as postoperative complications may be avoided by respecting a minimal delay between immunization and anaesthesia.

A delay of 48 hours is needed for children immunized with inactivated vaccine. On the other hand, there is no need to delay anesthetic in a child immunized with live vaccine if the child is well at preoperative assessment.

The influence of anaesthesia on various markers of immunity has been assessed in children, showing a decrease in absolute T- and B-lymphocyte counts after surgery that return to preoperative values within hours or days. This may represent the redistribution of immune cells from the peripheral blood to lymphatic tissues or local sites of trauma rather than immunodepression. All studies demonstrate a short-lived and reversible influence on lymphoproliferative responses that return to preoperative values within 24-48 h.

Perioperative catastrophes prompting anesthesiologists to consider career change!

The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey

Farnaz M. Gazoni, MD, Peter E. Amato, MD, Zahra M. Malik, MD, and Marcel E. Durieux, MD, PhD

Anesth Analg 2011

BACKGROUND: Most anesthesiologists will experience at least one perioperative catastrophe over the course of their careers. Very little, however, is known about the emotional impact of these events and their effects on both immediate and long-term ability to provide care. In this study, we examined the incidence of perioperative catastrophes and the impact of these outcomes on American anesthesiologists.

METHODS: We sent a self-administered postal survey to 1200 randomly selected members of the American Society of Anesthesiologists. Participants were sent an advance letter, up to 2 copies of the survey, up to 2 reminder postcards, and a small cash incentive. Six hundred fifty-nine physicians (56%) completed the survey.

RESULTS: Eighty-four percent of respondents had been involved in at least one unanticipated death or serious injury of a perioperative patient over the course of his/her career. Queried about the emotional impact of a “most memorable” perioperative catastrophe, 70% experienced guilt, anxiety, and relieving of the event with 88% requiring time to recover emotionally from the event and 19% acknowledging having never fully recovered. Twelve percent considered a career change. Sixty-seven percent of respondents believed that their ability to provide patient care was compromised in the first 4 hours subsequent to the event, but only 7% were given time off.

CONCLUSION: A perioperative catastrophe may have a profound and lasting emotional impact on the anesthesiologist involved and may affect his or her ability to provide patient care in the aftermath of such events.

The 2011 Guidelines for Coronary Artery Bypass Graft(CABG) surgery.

Important to Know.....

Now click and get to Know the updated guidelines for CBABG surgery

                                                     Click Here

Ephedrine and Phenylephrine Use during Cesarean Delivery: Which to choose?

A Review of the Impact of Phenylephrine Administration on Maternal Hemodynamics and Maternal and Neonatal Outcomes in Women Undergoing Cesarean Delivery

Ashraf S. Habib, MBBCh, MSc, MHS, FRCA

Anesth Analg 2011

Phenylephrine is effective for the management of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery under spinal anesthesia. While ephedrine was previously considered the vasopressor of choice in obstetric patients, phenylephrine is increasingly being used. This is largely due to studies suggesting improved fetal acid base status with the use of phenylephrine as well as the low incidence of hypotension and its related side effects with prophylactic phenylephrine regimens. This review highlights the effects of phenylephrine compared with ephedrine on many important aspects. Here is the conclusion.

Both ephedrine and phenylephrine are effective in managing spinal anesthesia-induced hypotension.

Phenylephrine may be associated with a lower incidence of IONV (Intraoperarive Nausea and Vomiting), and higher umbilical artery pH and base excess compared with ephedrine. However, the difference in pH is small and unlikely to be clinically relevant in low-risk deliveries.

Administration of phenylephrine as a prophylactic infusion is more effective in reducing the incidence of hypotension and IONV compared with bolus administration. However, phenylephrine use is associated with a decrease in maternal cardiac output. The clinical significance of this reduction in healthy low-risk parturients is unclear. Studies suggest that such changes do not appear to have any consequences in healthy mothers. The optimum phenylephrine administration regimen is unclear. Studies addressing the use of phenylephrine in high-risk pregnancies, such as those complicated by placental insufficiency, preeclampsia, and growth restriction, are needed.

Sodium Bicarbonate..another weapon to control High ICP

Bicarb for raised ICP

This is a really interesting paper, suggesting a good alternative to hypertonic saline that avoids the problems of hyperchloraemmic metabolic acidosis: Background  Hypertonic saline is routinely used to treat rises in intracranial pressure (ICP) post-traumatic head injury. Repeated doses often cause a hyperchloremic metabolic acidosis. We investigated the efficacy of 8.4% sodium bicarbonate as an alternative method of lowering ICP without generating a metabolic acidosis. Methods  We prospectively studied 10 episodes of unprovoked ICP rise in 7 patients treated with 85 ml of 8.4% sodium bicarbonate in place of our usual 100 ml 5% saline. We measured ICP and mean arterial pressure continuously for 6 h after infusion. Serum pH, pCO2, [Na+], and [Cl−] were measured at baseline, 30 min, 60 min and then hourly for 6 h. Results  At the completion of the infusion (t = 30 min), the mean ICP fell from 28.5 mmHg (±2.62) to 10.33 mmHg (±1.89),P < 0.01. Mean ICP remained below 20 mmHg at all time points for 6 h. Mean arterial pressure was unchanged leading to an increased cerebral perfusion pressure at all time points for 6 h post-infusion. pH was elevated from 7.45 ± 0.05 at baseline to 7.50 ± 0.05, P < 0.01 at t = 30 min, and remained elevated. Serum [Na+] increased from 145.4 ± 6.02 to 147.1 ± 6.3 mmol/l, P < 0.01 at t = 30 min. pCO2 did not change. Conclusions A single dose of 8.4% sodium bicarbonate is effective at treating rises in ICP for at least 6 h. Serum sodium was raised but without generation of a hyperchloremic metabolic acidosis

NEUROCRITICAL CARE
Volume 13, Number 1, 24-28, DOI: 10.1007/s12028-010-9368-8
Sodium Bicarbonate Lowers Intracranial Pressure After Traumatic Brain Injury Chris Bourdeaux and Jules Brown

Differences between air and carbon dioxide emboli

Carbon dioxide embolism must be distinguished from air embolism, a far more ominous event, as shown in the table below. Carbon dioxide being extremely soluble in the presence of red blood cells, is much less life threatening than an identically sized intravascular bolus of air.

Embolism	Air	CO2
Composition	79% N2, 21% O2	100% CO2
Position	Sitting position	Any
Origin	Vein open to air	No contact with air
Pressure source	Hydrostatic	insufflator
Solubility	Negligible	Large
Effect of N2O	Enlarged	Not enlarged

7 lethal effects of metabolic acidosis

The net effect of severe metabolic acidosis:

1. Impaired cardiac contractility
2. Decreased threshold for V-Fib
3. Decreased Hepatic and Renal flow
4. Increased pulmonary vascular  resistance
5. Inability to respond to vasopressors
6. Inhibition of coagulation factors and platelets
7. vascular collapse

High Flow nasal cannula beats CPAP

Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation.

High-flow nasal cannulas (HFNC) have been adapted from use in neonates to adults to deliver continuous positive airway pressure (CPAP).

HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx. Patients tolerate it well and it is less claustrophobic than tight-fitting masks.

HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula) and non-invasive positive pressure ventilation with tight-fitting masks.

Check with your respiratory department if these devices are locally available.

Kernick, j. What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Crit Care. 2010 May;23(2):53-70. Epub 2010 Mar 5.

Parke, R. A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients. Respir Care. 2011 Mar;56(3):265-70. Epub 2011 Jan 21.

BiPAP..3 simple rules to put it ON

BiPAP now is being used on a wide scale in perioperative medicine  and in critical care units.

Today we will discuss the three basic simple rules on How to start it and then adjust your parameters according to the clinical situations?

BiPAP – usually start at 8/3 (the first digit is IPAP the second EPAP) and keep IPAP 5 above EPAP.

If the patient has hypoxemia EPAP and IPAP should go up in 2 cm H2O increments.

Hypercarbia- increase IPAP in 2 cm increments.

Easy...............

Tomorrow we will discuss the evidence based  use of BiPAP

Continuous spinal anesthesia: what's new?

-Continuous spinal anaesthesia combines the advantages of single-dose spinal anaesthesia, rapid onset and a high degree of success, with those of a continuous technique.

-The introduction of micro-catheters invigorated interest in the technique and allowed its expansion to additional populations and surgical procedures. However, multiple cases of cauda equina syndrome associated with micro-catheters and (primarily) hyperbaric lidocaine solution led to withdrawal of micro-catheters from the US market.

-In 1992, FDA banned the use of spinal catheters thinner than 24G after 12 cases of cauda equina.

20G cathters are recommended in geriatric patients.

-Continuous spinal anesthesia provides adequate level and duration of anesthesia in elderly and high risk patients undergoing lower abdominal and lower limb surgery

-Indications: postoperative analgesia, chronic pain relief, previous spinal surgery, procedures of unpredictable length, significant cardiac disease, morbid obesity, difficult epidural catheter placement, difficult airway.

-Plain bupivacaine 0.5% is a safe local anesthetic during continuous spinal anesthesia.

Low CVP Hepatectomy..What is good and What is Bad?

Blood loss is affected by central venous pressure during Hepatectomy.

When central venous pressure is maintained at <5 mm Hg, blood loss is predictably lower than when central venous pressure is> 6 mm Hg.

In the original publication describing low central venous pressure approaches to hepatic resection, median blood loss was only 200 mL, with most patients in the low central venous pressure study group not requiring transfusion.

In contrast, when central venous pressure was ≥ 6 mm Hg, median blood loss was 1 L and half of the patients required transfusion.

Low central venous pressure approaches affect outcomes beyond transfusion and blood loss, as reflected in longer hospital stays for patients whose central venous pressure was >6 mm HG during hepatic resection.

Low central venous pressure anesthesia apparently is safe with respect to renal function.

Only 3% of patients experience any degree of permanent renal dysfunction after hepatic resection

using a low central venous pressure technique.

However, these favorable outcomes are predicated on maintaining good renal perfusion pressure (typically believed to be ≥ 60 mm Hg).

Obviously the risk of severe air embolism is elevated under low central venous pressure conditions, and the anesthesia team must be highly vigilant for such an event.

Reports in the surgical literature caution that extreme care must be taken during dissection of the liver so as not to make holes in the hepatic veins, which can lead to catastrophic hemorrhage or air embolism.

1. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection.

 Br J Surg 1998;85:1058–1060.

2. Smyrniotis V, Kostopanagiotou G, Theodoraki K, et al. The role of central venous pressure and type of vascular control in blood loss during major liver resections.

Am J Surg 2004;187:398–402.

neuroaxial anesthesia and Multiple sclerosis

Although regional central conduction blockade, and especially spinal anesthesia, has been implicated in the exacerbation of MS , the studies are very small.

Local anesthetic neurotoxicity has been speculated as being a more likely in nerves which are demyelinated, i.e. in MS patients.

As such, theoretically epidural anesthesia may be less of a risk as concentrations of local anesthetic in the white matter of the spinal cord are lower than with spinal anesthesia

Overall, however, the use of epidural anesthesia appears safe. Bader et al. noted that in women who received epidural anesthesia for vaginal delivery, relapse rates were similar to those who received local infiltration. Additional prospective and randomized studies will need to be conducted to evaluate the true relationship between regional anesthesia and MS exacerbations.

ischemic stroke... stop lowering pressure

Severely elevated blood pressure (BP) and aggressive BP reduction are both associated with poor outcome in acute ischemic stroke (AIS).

Because many stroke patients have long-standing hypertension, blood pressure lowering may result in cerebral hypoperfusion and worsening ischemia.

 It is generally accepted that elevated blood pressures should not be lowered, unless:

• the patient has received thrombolytic treatment
• has a hypertensive emergency (aortic dissection, hypertensive encephalopathy, acute renal failure, acute pulmonary edema, or acute myocardial infarction); 
•  contraindication to elevated blood pressure, such as recent surgery.

The American Stroke Association guidelines recommend that antihypertensive agents should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg . If patients have received thrombolytic therapy, the guidelines advocate maintaining systolic blood pressure less than or equal to 180 mm Hg and diastolic blood pressure less than or equal to 105 mm Hg .

If blood pressure lowering is indicated, it should be instituted cautiously to avoid hypotension.

Acute Heart Failure syndrome made simple

• Acute heart failure syndrome (AHFS) spectrum can be divided into 5 groups as regards therapeutic management: 
• (i) Dyspnoea + /- congestion with elevated systolic blood pressure (SBP)>140 mmHg, usually with abrupt onset (acute pulmonary oedema) APO (most frequent type)
• (ii) Dyspnoea + /- congestion with normal SBP 100-140 mmHg, usually with gradual onset predominant systemic oedema and milder APO
• (iii) Dyspnoea + /- congestion with low SBP <100 mmHg, with predominant cardiogenic shock or end-stage cardiac failure (most fatal type)
• (iv) Dyspnoea + /- congestion with signs of ACS such as chest pain
• (v) Isolated RV failure usually without APO.

• Treatment aims

  • Decrease left ventricular diastolic pressure, by decreasing systemic vascular resistance and improving systolic and diastolic functional reserve.
  • Promote coronary blood flow.
  • Correct acute respiratory failure.
  • In-hospital mortality for APO is up to 12%, with one-year mortality up to 40%.

• Drugs

• Nitroglycerin S/L, topical or IV titrated to avoid hypotension.
• Most rapidly venodilates, reduces LV afterload and corrects myocardial ischaemia. Ideal for AHFS type 1. (i) above.
• Also consider in AHFS types 1. (ii) and (iv) if SBP > 110 mmHg.
• Avoid in AHFS type 1. (iii) above.
• Nitrates are used less often than frusemide + were used in just 27% of the patients admitted in the ADHERE registry (USA, 2003)

• Frusemide IV.  Despite universal use, absolute efficacy is unclear. May cause decrease in cardiac output and increase PVR, plus increase PAOP in more chronic HF. Ideal for AHFS type 1. (ii) above.

• ACE inhibitor IV, orally or SC also reduces pre- and afterload, but little data in acute situation. Precipitous hypotension is hard to reverse, so use is best reserved for longer term management of HF.

• Morphine has relatively ineffective / unproven acute venodilating and sympatholytic effects, is rarely used (3% one study) and may result in respiratory depression in face of NIV and/or a poorer outcome. May have role in APO with diastolic dysfunction (ie. EF >40%) with elevated SBP.

• Traditional inotropic support is with dobutamine, dopamine, milrinone, enoximone or salbutamol for AHFS type 1. (iii) above, but may disastrously increase myocardial oxygen demand, especially in ACS with AHFS type 1. see (iv) above. Rarely need to add vasoconstrictor noradrenaline.

TURP from monopolar to bipolar..TURP syndrome vanish

Monopolar TURP

The conventional gold standard for TURP was the monopolar electrode resectoscope. With the monopolar electrode, layers of prostatic tissue are resected with a cutting current transmitted through a single-limb electrode which exits the patient by way of a grounding pad.

A non-electrolyte bladder-irrigating solution is required to avoid dispersion of the electrical current as well as tissue damage at the site of prostatic resection. TURP syndrome is a potentially serious complication which can occur when a nonelectrolyte, hypoosmolar bladder-irrigating solution is used.

Bipolar TURP

Bipolar TURP electrode technology incorporates a continuous loop electrode to resect prostatic tissue of BPH. This surgical tool is designed to contain the inflow and outflow of current via the resectoscope for prostatic tissue resection. By being completely self-contained within the bipolar unit, the current is prevented from passing through the patient.

The advantage of this system is that for the bladder-irrigating solution, an electrolyte-containing solution such as normal saline can be used.

Although intravascular absorption of normal saline can occur via resected prostatic veins opened during prostatic resection, hypoosmolality and hyponatremia associated with TURP syndrome are prevented. Nevertheless, the risk of volume overload as a consequence of the bladder-irrigating solution can still occur with the bipolar TURP technique.

In a review of 16 studies conducted over a 10-year period, Issa compared the safety properties of monopolar and bipolar TURP . He found a statistically significant decrease in overall complication rate,

transfusion rate, and TURP syndrome with bipolar TURP.(1)

1-Issa MM. Technological advances in transurethral resection of the prostate: bipolar versus monopolar TURP.

J Endourol. 2008; 22(8):1587-95.

Troponin elevation..not only Cardiac

Here is the list of the different causes that elevate Troponin..as you will see ,not only ACS that result in Troponin elevation:

Reasons for acutely elevated Troponin:

ACS
Acute heart failure
PE
Stroke
Aortic dissection
Tachyarrhythmias
Shock
Sepsis
Perimyocarditis
Endocarditis
Tako-tsubo cardiomyopathy
Cardiac contusion
Strenuous excercise
Sympathomimetic drugs
Chemotherapy
 
Agewall S, Giannitsis E, Jernberg T, et al. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011;32:404-411.

Anesthesia And Obesity...important facts

Expiratory reserve volume is the most sensitive indicator of the effect of obesity on pulmonary function testing.

Plasminogen activator inhibitor-1 (PAI-1), which is secreted by  adipocytes  associated with visceral obesity inhibits the fibrinolytic system. PAI-1 decreases fibrinolysis and increases the risk of coronary artery disease.

Gastric emptying is delayed in obese patients because of increased abdominal mass that causes antral distension, gastrin release, and a decrease in pH with parietal cell hypersecretion.

The magnitude of body mass index does not have much influence on the difficulty of laryngoscopy.

Neck circumference has been identified as the single biggest predictor of problematic intubation in morbidly obese patients

Preoxygenation in the head-up or sitting position is more effective and provides the longest safe apnea period during induction of anesthesia in obese patients.

Positive end-expiratory pressure is the only ventilatory parameter that has consistently been shown to improve respiratory function in obese subjects

Rhabdomyolysis has been documented in morbidly obese patients undergoing prolonged procedures. Elevations in serum creatinine and creatine phosphokinase levels unexplained by other reasons and complaints of buttock, hip, or shoulder pain in the postoperative period should raise the suspicion of rhabdomyolysis.

Forearm blood pressure is a fairly good predictor of upper arm blood pressure in most patients; however, forearm measurements with a standard cuff may overestimate both systolic and diastolic blood pressures in obese patients.