Ventilate and Intubate But Don’t Forget Communicate

Many years ago I was participating in a volunteer medical mission to Kenya when I learned a valuable lesson in communication which I often share with my students. It involves a failure to communicate on multiple levels that almost caused some major problems. Read More …

Avoiding Medication Errors

Humans are fallible and medication errors are very easy to permit’s easy to give a medication error if you aren’t constantly vigilant. Presented are a series of steps to perform every time a medication is administered that will help prevent medication error. Read More …

Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation

Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations. This technique is particularly helpful during blind nasal intubation or fiberoptic intubation in young children after induction of general anesthesia for surgery, although it can be used in adults. Here we discuss use of this technique for a case of accidental extubation of a patient with Ludwig’s Angina.
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How Does Hypoventilation Cause Hypoxemia?

I often find that my students sometimes confuse oxygenation and ventilation as the same process. In reality they are really very different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body.Why do we need to understand this? Let’s look at some common examples. Along the way we will painlessly use the Alveolar Gas Equation to explain two common scenarios:
how hypoventilation causes hypoxia,
why abruptly taking all supplemental oxygen away from a carbon dioxide retainer will hurt them. Read More …

Tongue Necrosis From Endotracheal Tube Compression

Tongue necrosis from compression by an endotracheal tube or oral airway is a rare, but devastating complications when it occurs. It can occur with poor endotracheal tube positioning, flexed head and neck positioning, impaired blood flow, and shock. It is important to familiarize ourselves with this entity so that we as anesthesia providers can minimize the risks.
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Plastic In the Airway: An Unsuspected Aspiration Hazard

I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two. Take a look Read More …

A Case of Endotracheal Tube Obstruction

Normally we view patients who are intubated as being protected in terms of ventilatory support. However, being intubated makes the patient vulnerable to a variety of potential problems. Rapid deterioration of an intubated patient can be a challenging and frightening scenario because the providers must rapidly troubleshoot the causes as well as treat. Here a case of endotracheal tube obstruction and its management is described. Read More …

Our Procedural Cast Offs Can Place Our Patients at Risk of Pressure Injury

Health care workers are sometimes careless when it comes to leaving discarded odds and ends that come with our needles and catheters in patient beds. These objects can cause pressure sores and nerve injuries, especially inpatients who are at high risk of pressure injury. We must always be alert to safeguard our patients. Read More …

Protect Yourself From Infection In The Workplace

There are several animal and avian viruses that show the potential of becoming easily transmissible to humans. MERS, H7N9 and H5N1 are already spreading in humans, although not easily. The last major jump from animal to human occurred with the 1918 flu pandemic where an estimated 40 million people died. Mortality from MERS is currently 330-40% in the Middle East and 10% in South Korea. As health care workers, how we approach infectious disease precautions will have a lot to do with how safe we and our patients are in the workplace. Read More …

Risks of Placing Your Endotracheal Cuff Too High

When intubating, we all know to check the depth of the endotracheal tube. Most people believe this is just to ensure that the tube is not too deep and therefore causing a mainstem intubaton: intubating just one bronchus and therefore only one lung. However, there are significant risks with having the tube too shallow as well, risks such as accidental extubation and potentially causing permanent damage to the recurrent laryngeal nerves. Here we discuss some of the warning signs that the cuff is too high and what to do about it. Read More …

Should I Use A Cuffed or Uncuffed Endotracheal Tube In a Child?

When intubating children, the question always arises whether to use a cuffed or an uncuffed endotracheal tube (ETT). Historically uncuffed endotracheal tubes have been used when the child is less than about 8 years old. Why is it that we can get away with using an uncuffed tube in a young child, but not an adult? The answer comes from the difference in airway anatomy between child and adult. Understanding the advantages and disadvantages of using uncuffed and cuffed tubes in children is important to safe patient care. Read More …

Embrace the Catastrophist Within: Protecting Ourselves From Respiratory Infection

A good anesthesiologist, or any health care provider, has to embrace the catastrophist within because our goal is to protect our patients from the unexpected. We have to constantly imagine the worst-case scenario so that if, or when, it happens we not only recognize it early, we’re ready for it. What we’re often not good at is protecting ourselves at work. We tend to be so patient focused that we often don’t even think about personal hazards. This article discusses some of the risks we face during airway management of the infectious patient. Read More …

Laryngospasm is a Life-Threatening Emergency

One of the more frightening events in anesthesia is laryngospasm: the protective, reflex, spasmodic closure of the vocal cords that occurs when the vocal cords are stimulated. This article discusses the mechanism of laryngospasm, and how to treat it. Read More …

Communication Is Everything

Given the difficulty of working with a volunteer team in the developing world, how do we take strangers and quickly transform them into a cohesive, well-functioning team in a difficult environment? Let’s look at some of the tools we use. Read More …

When The Power Goes Out In The OR

While power failures in hospitals in the United States are thankfully rare, they do happen. This discussion offers tips on dealing with power failure in the OR while working in the developing world. Read More …

Opioid Induced Respiratory Depression: A Balance in the Force

Postoperative opioid-induced respiratory depression is common and results from an imbalance in the forces of arousal vs the forces of sedation. Opioid induced respiratory depression requiring treatment can occur to any patient at any time, and under the care of any provider — from novice to experienced. You must understand the forces of sedation and arousal and be constantly vigilant to keep your patients safe. Read More …

Beware: Your Patient Can Bite That Pilot Tube

Persistent endotracheal tube leaks may require the need to exchange the endotracheal tube in a critical patient or situation. The differential diagnosis of such leaks is discussed. In addition, a case regarding a patient biting a pinhole in the pilot tube of their endotracheal tube is presented. Read More …

Tricks For LMA Insertion

The LMA provides an alternate means to ventilate a patient during surgery — without intubation and while freeing the provider’s hands from having to hold the mask. It provides a more secure airway that makes gastric distention less likely. Since its invention, the LMA has since become quite valuable as a rescue device in situations when intubation may be difficult — even for the inexperienced. Let’s talk about some tips for successful insertion. Read More …