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Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored.
Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed.
Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors.
Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.
The modern practice of sedation is the end result of a process of evolution in alteration of consciousness, likely starting with the discovery of the analgesic properties of ether. Recent technological advances have drastically changed the practice of sedation. One of the most significant was certainly the development of pulse oximetry during World War II by Glen Millikan. In 2002, the American Society of Anesthesiologists (ASA) appointed a task force to update practice guidelines for non-anesthesiologists administering sedation and analgesia. The Association of periOperative Registered Nurses (AORN) has produced guidelines for what every registered nurse should know about "conscious sedation". According to the AORN, moderate sedation/analgesia is produced by the administration of amnesic, analgesic, and sedative pharmacologic agents. With continued attention to a high standard of safety, many different professionals are able to provide sedation services to those patients who need them.
An integral part of the practice of gastrointestinal endoscopy is adequate sedation and analgesia. The choice of the appropriate sedation modality is always a balance between optimizing the benefits of sedation and minimizing the potential risks. The American Society of Anesthesiologists (ASA) agrees that appropriate pre-procedure evaluation increases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes. A vast majority of endoscopic procedures are diagnostic in nature and performed on relatively healthy patients with an ASA status of 1 or 2. Diagnostic and therapeutic endoscopic interventions include esophagogastroduodenoscopy (EGD), proctoscopy/sigmoidoscopy/colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Sedation for gastrointestinal endoscopy is particularly challenging because of variability during most procedures, characterized by long nonstimulating periods interspersed with significantly stimulating events. Use of a medication reconciliation tool is associated with significant improvements in patient safety.
Do-not-resuscitate (DNR) orders may be written if cardiopulmonary resuscitation (CPR) would be physiologically futile, or at the request of patients who feel that CPR would result in poorer quality of life. Pre-hospital DNR policies have emerged recently and serve three primary purposes: to provide continued respect for patient autonomy following hospital discharge, prevent futile resuscitation efforts in the field, and protect the well-being of emergency medical service (EMS) personnel. This chapter explains this concept citing the case study of a 67-year-old male with oxygen-dependent COPD requiring a series of electroconvulsive therapies (ECT) for severe depression refractory to medical therapy. Patients with preexisting DNR orders often require anesthesia for surgical procedures necessitated by the need to improve quality of life. The American Society of Anesthesiologists and the American College of Surgeons have drafted guidelines for the management of the patient with a presurgical DNR order.
Reports of anesthesia-related deaths in obstetric practice point to difficulties with airway management in morbid obesity (MO) parturients as the primary cause. A large proportion of patients recruited for airway studies in MO are recruited from bariatric surgical populations, which typically exhibit a large preponderance of female patients. Numerous anatomic factors contribute to difficult airway management in the MO patient. This chapter presents options for airways management in an order that reflects their application in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm. Awake intubation maintains airway patency and spontaneous respiration, but is not without hazard in this difficult patient group. Flexible fiberoptic laryngoscopy is the most common technique chosen for awake intubation, but visualization may be difficult when excess fat deposition results in airway narrowing and redundant folds of tissue. Equal care and equipment should be available for extubation as well as intubation.
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