Current Clinical Strategies Handbook of Anesthesiology

Anesthesiology, 1997

Pediatric Clinics of North America, 2004

Pediatric emergency care, 2009

To prospectively investigate whether American Society of Anesthesiologists (ASA) class, as assigned by nonanesthesiologists, is associated with adverse events during procedural sedation in a pediatric emergency department. Methods: A prospectively collected database of children aged 0 to 21 years undergoing procedural sedation in the emergency department of an urban, tertiary care, children's hospital was retrospectively reviewed. This database included clinical and demographic characteristics, including assigned ASA class. It also included information relative to the procedure, the sedation, and any complications related to the sedation. Complications were defined a priori as persistent oxygen desaturation to less than 93% on pulse oximetry requiring supplemental oxygen, bronchospasm, dizziness, apnea, seizure, hiccoughs, laryngospasm, stridor, arrhythmia, hypotension, rash, vomiting, aspiration, or a disinhibition/agitation/dysphoria emergence reaction. Main outcome measure was the incidence of complications relative to ASA class. Results: Procedural sedation was performed in the emergency department 1232 times during the study period; 30 sedations did not have either ASA class or occurrence of a complication recorded. Thus, 1202 sedations were included in the study. Nine hundred eighty-eight patients were classified as ASA class 1, whereas 214 were classified as ASA class 2 or greater. There were a total of 215 adverse events in the study population. Most of these were hypoxia (185 total) and were more likely to occur in patients with an ASA class 2 or greater (P = 0.021). Conclusions: Adverse events during procedural sedation are more common in patients with higher ASA class.

The Journal of Trauma: Injury, Infection, and Critical Care, 2004

everely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O 2 requirements), including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. 1 Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis (compensated shock), which may lead to organ dysfunction and death. Use of the endpoints discussed in this guideline may allow early detection and reversal of this state, with the potential to decrease morbidity and mortality from trauma. Without doubt, resuscitation from hemorrhagic shock is impossible without hemostasis. Fluid resuscitation strategies before obtaining hemostasis in patients with uncontrolled hemorrhage, usually victims of penetrating trauma, remain controversial. Withholding fluid resuscitation may lead to death from exsanguination, whereas aggressive fluid resuscitation may disrupt the clot and lead to more bleeding. "Limited," "hypotensive," and/or "delayed" fluid resuscitation may be beneficial, but clinical trials have yielded conflicting results. This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further. Use of the traditional markers of successful resuscitation, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care per the Advanced Trauma Life Support Course. When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. After normalization of these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing metabolic acidosis or evidence of gastric mucosal ischemia. This condition has been described as compensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death. Consequently, better markers of adequate resuscitation for severely injured trauma victims are needed. This guideline committee sought to evaluate the current state of the literature regarding use of potential markers and related goals of resuscitation, focusing on those that have been tested in human trauma victims. This manuscript is part of an ongoing process of guideline development that includes periodic (every 3-4 years) review of the topic and the recommendations in light of new data. The goal is for these guidelines to assist clinicians in assuring adequate resuscitation of trauma patients, ultimately improving patient outcomes. 1. To demonstrate that the proposed endpoints are useful for stratifying the patients' severity of physiologic derangement. 2. To demonstrate that the proposed endpoints are useful for predicting risk of development of MODS or death. 3. To determine the endpoints for resuscitation that would predict survival without organ system dysfunction if a defined level is achieved within a certain time frame. 4. To improve patient survival and morbidity (organ

Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2012

Purpose The constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation. Principal findings Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient’s comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly. Conclusions Recommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest. Objectif Le grand ensemble d’événements liés à la réanimation cardiaque avancée (ACLS) tels que les embolies gazeuses, les surdosages d’anesthésiques locaux et la bradycardie sinusale dans un contexte périopératoire est différent des événements que l’on observe à l’extérieur de l’hopital. En conséquence, une modification des protocoles traditionnels d’ACLS permet une réanimation plus spécifique, en fonction de l’étiologie. Constatations principales Les arrêts cardiaques en période périopératoire sont à la fois rares et hétérogènes; ils n’ont pas été décrits ou étudiés avec la même ampleur que les arrêts cardiaques survenant hors de l’hôpital. Ces crises sont habituellement vécues en direct, souvent anticipées et impliquent l’intervention d’un médecin connaissant les comorbidités du patient ainsi que la physiopathologie en rapport avec l’intervention et les anesthésiques utilisés. Lorsque le professionnel de la santé identifie la cause probable de l’arrêt cardiaque, le praticien a la possibilité d’entreprendre rapidement une prise en charge médicale. Conclusions Des recommandations pour la prise en charge doivent être fondées sur les avis d’experts et sur la compréhension de la physiologie plutôt que sur des normes actuellement utilisées pour la création de protocoles d’ACLS hors du milieu hospitalier. L’adaptation des algorithmes d’ACLS et la prise en compte des diagnostics différentiels de ces événements périopératoires peuvent prévenir les arrêts cardiaques.

2021

Apgar Score (AS) < 7 is a predictor of mortality. Survival is shorter in newborns, with AS 5min < 7 and the use of invasive mechanical ventilation (IMV). Thus, the objective of this study was to analyze whether maternal, obstetric, anthropometric, and postnatal variables of newborns admitted to the neonatal intensive care unit (NICU) may be associated with AS 5min < 7. If this score is a predictor of morbidity and mortality, and if factors most associated with the worse AS interfere with survival. This observational, retrospective, and quantitative study used a descriptive and inferential approach to analyze the medical records of patients of both sexes treated in the NICU of a tertiary hospital which is a recognized reference center of maternal and child health, during 2017. Data were collected to verify the relationship between AS values (AS 5min < 7 and AS 5min ≥ 7). AS 5min < 7 was associated with hypertensive disorders of pregnancy (HDP), premature rupture of the amniotic membrane, vaginal delivery, fetal trauma at birth, abdominal perimeter, and ventilatory support. Among these, HDP and the use of IMV were predictors of lower survival. Conclusion: AS 5min was associated with maternal, obstetric, anthropometric, and postnatal variables of neonates admitted to the NICU. Speci c maternal and postnatal variables interfered with the survival of these newborns.

Many key issues in the review of the pediatric advanced life support literature resulted in refinement of existing recommendations rather than in new recommendations. New information or updates are provided about fluid resuscitation in febrile illness, atropine use before tracheal intubation, use of amiodarone and lidocaine in shock-refractory VF/pVT, TTM after resuscitation from cardiac arrest in infants and children, and post–cardiac arrest management of blood pressure. In specific settings, when treating pediatric patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival. This contrasts with traditional thinking that routine aggressive volume resuscitation is beneficial. Routine use of atropine as a premedication for emergency tracheal intubation in non-neonates, specifically to prevent arrhythmias, is controversial. Also, there are data to suggest that there is no minimum dose required for atropine for this indication. If invasive arterial blood pressure monitoring is already in place, it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest. Amiodarone or lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF and pVT in children. Epinephrine continues to be recommended as a vasopressor in pediatric cardiac arrest. For pediatric patients with cardiac diagnoses and IHCA in settings with existing extracorporeal membrane oxygenation protocols, ECPR may be considered. Fever should be avoided when caring for comatose children with ROSC after OHCA. A large randomized trial of therapeutic hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia (with temperature maintained at 32°C to 34°C) or the strict maintenance of normothermia (with temperature maintained 36°C to 37.5°C) was provided. Several intra-arrest and post–cardiac arrest clinical variables were examined for prognostic significance. No single variable was identified to be sufficiently reliable to predict outcomes. Therefore, caretakers should consider multiple factors in trying to predict outcomes during cardiac arrest and in the post-ROSC setting. After ROSC, fluids and vasoactive infusions should be used to maintain a systolic blood pressure above the fifth percentile for age. After ROSC, normoxemia should be targeted. When the necessary equipment is available, oxygen administration should be weaned to target an oxyhemoglobin saturation of 94% to 99%. Hypoxemia should be strictly avoided. Ideally, oxygen should be titrated to a value appropriate to the specific patient condition. Likewise, after ROSC, the child's Paco should be targeted to a level appropriate to each patient's condition. Exposure to severe hypercapnia or hypocapnia should be avoided. 2 Recommendations for Fluid Resuscitation 2015 (New): Early, rapid IV administration of isotonic fluids is widely accepted as a cornerstone of therapy for septic shock. Recently, a large randomized controlled trial of fluid resuscitation conducted in children with severe febrile illnesses in a resource-limited setting found worse outcomes to be associated with IV fluid boluses. For children in shock, an initial fluid bolus of 20 mL/kg is reasonable. However, for children with febrile illness in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution, as it may be harmful. Individualized